[Congressional Record (Bound Edition), Volume 155 (2009), Part 24]
[Senate]
[Pages 32928-32963]
[From the U.S. Government Publishing Office, www.gpo.gov]




             SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009

  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. I yield 20 minutes to the chairman of the HELP Committee, 
Senator Harkin, and 18 minutes to the Senator from Colorado, Senator 
Bennet.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. HARKIN. Mr. President, I guess I can say we crossed the Rubicon 
last night at 1 o'clock. Reading some of the press reports, of course, 
most of the news didn't have it because it occurred at 1 a.m. Some of 
the different reports have been online this morning. It occurred to me 
that a lot of people are missing the overall importance of what 
happened last night. We can get into the fine tuning and the nitpicking 
and sort of the fear and the anger I hear from the other side. Every 
time I listen to speeches over there, with the exception of the last 
speaker, almost all the speeches I hear from the other side, it is 
fear, be afraid, be afraid. It is some built-up anger over there. I 
think what happened last night is, we crossed a demarcation line, the 
demarcation line of which on one side health care is a privilege. We 
have been on that side of the line for a long time. On the other side 
of that line, health care is a right. We stepped across that line last 
night. We are now in the process of saying health care is a right, an 
inalienable right of every American citizen.
  Is that what so upsets my friends on the Republican side? I don't 
know. Something is upsetting them. Because this is a momentous change 
we are doing.
  I keep hearing from Republicans they want us to deal in a bipartisan 
way. We tried all this year, both in the HELP Committee and in the 
Finance Committee. Senator Baucus bent over backward to accommodate. 
But at every turn, Republicans said no, no, no, no, no--all year long. 
How can you be bipartisan when the other side has nothing to offer? 
There is no bill on the Republican side. There is a bill. It has about 
nine cosponsors--Senator Coburn, Senator Burr, maybe seven others, but 
not every Republican is on that. I hear bits and pieces of this and 
that every time I hear these speeches. Most of it is attacking what we 
have done. I hear nothing positive from their side. It is very hard to 
deal with a party that is in total disarray as the Republicans are. If 
they had a bill they were supporting and that was supported by all of 
them, such as the bill we have here which is supported by 60 Democrats, 
I think then you could find some reason for meeting and working things 
out. But since there is no one on that side who has a comprehensive 
proposal, it is hard to do that. We have had to kind of plow ahead as 
best we can. We have not done this alone. In our committee, we met for 
13 days. We had 54 hours of markup. No amendment was denied. 
Republicans offered over 200 amendments. We adopted 161 of them. That 
is pretty good. Yet in the end, every Republican voted against it. So 
it is not as if we didn't try and we didn't hold out an olive branch to 
work with people to get a bill that was truly bipartisan. We did in our 
committees, both the Finance and HELP Committees. Now it has come down 
to fear and anger on the other side and some nitpicking.
  My friend from Iowa--and he is truly my friend--was talking about 
some provisions put in the bill for special reasons and so forth. I 
admit fully and openly that I was part of that. Did I put something in 
the bill that was sort of particular to my State of Iowa? Yes, I did. 
But it doesn't just affect Iowa. There are several States in which we 
have hospitals that are not as big as the big hospitals with the 
volume. They are not so small that they are low-volume hospitals that 
get help. They are kind of in between. They call them tweener 
hospitals. We have eight of them in Iowa: at Grinnell, Keokuck, Spencer 
Municipal, in Carroll, St. Anthony Regional; Muscatine; Fort Madison; 
and Lake Regional Hospital at Spirit Lake. There are a number of these 
in the United States. I forget the total number; not a large number, 
they just fall in a place where they are too small for the big and too 
big for the small. As a result, they have been getting a bad deal from 
Medicare reimbursement. There is a fix in this bill that will allow 
them to get adequate reimbursement. I don't see anything wrong with 
that. It is fixing a specific problem that the bureaucracy can't seem 
to quite get fixed. That is in the bill. I make no bones about having 
put that in there. I think it is a good deal. It is something that is 
going to help a lot of hospitals, not only in Iowa but a few other 
States.
  One of the things I wish to talk about today is something I have been 
on for many years, and that is the huge amount in this bill on 
prevention and wellness. It has not been written about a lot. People 
have been focused on the public option and the abortion issue and a few 
other items such as that. Perhaps one of the most profound parts of 
this bill and the one I believe will do more to bend the cost curve, as 
they say, than any other single thing is the provisions dealing with 
prevention and wellness. In the past I have said many times that we 
don't have a health care system in America. We have a sick care system. 
When you think about it, if you get sick, you get care. But precious 
little is spent out there to keep one healthy in the first place. So 
people get sick. You go to the doctor, the hospital. We patch and fix 
and mend and try to make them well.
  Your mother was right, you know: Prevention is worth a pound of cure. 
We have fallen far short of that in this country. There is a remarkable 
array of provisions in this bill that promote wellness, disease 
prevention, and public health. Together they will move us from a sick 
care society into a genuine wellness society, into a true health care 
system, not just sick care. What better way to reform our health care 
system than to restrain health care costs by helping Americans to 
prevent chronic diseases, stay healthy and out of the hospital in the 
first place. Right now, as we have heard so many times, we spend more 
than $2 trillion each year on sick care. But 4 cents of every dollar is 
invested in prevention and public health. I submit this is a major 
reason why Americans spend twice as much per capita on health care as 
European countries, but we are twice as sick with chronic disease. We 
spend twice as much as Europe on health care, but we are twice as sick 
with chronic diseases.
  The good news is that by ramping up the emphasis on wellness and 
prevention, we have tremendous opportunities to both improve the health 
of the American people and to restrain health care spending. That is 
the aim of this bill which makes significant new investments in 
prevention. For example, our bill would ensure that seniors have access 
to free annual wellness visits and personalized prevention plans under 
Medicare. We have never had that. For the first time seniors will have 
access to free annual wellness visits and personalized prevention plans 
under Medicare. That is a big deal. So many seniors today, if they get 
sick, go to the doctor and get more pills. Now they will be able to go 
in, have their annualized checkup, see what is wrong, and have a 
personalized prevention plan for each person under Medicare.
  It will also encourage States to improve coverage and access to 
recommended preventative services and immunizations under Medicaid. At 
a minimum, States will provide Medicaid coverage for comprehensive 
tobacco cessation services for pregnant women. That is just the start. 
Right away, at a minimum, they have to do that. In addition, the bill 
requires insurance companies to cover recommended preventive services 
with no copayments or deductibles. This is critical because we know 
that all too often people forgo their yearly checkups or essential

[[Page 32929]]

screenings because either their insurance companies don't cover them or 
because they have high copays and deductibles.
  Another critical element in the bill essential to a sustainable push 
for wellness is the creation of a prevention and public health trust 
fund. Typically prevention and public health initiatives are subject to 
unpredictable and unstable funding. This means that important 
interventions, things such as education about nutrition and assistance 
for smokers who want to quit, often go unfunded from one year to the 
next. They get funded a little bit one year or cut the next; funded a 
little bit the next year, cut the next. The prevention and public 
health fund in this bill will provide an expanded and sustained 
national investment in programs that promote physical activity, improve 
nutrition, and reduce tobacco use. We all appreciate that checkups and 
immunizations and other clinical services are important. But this bill 
also recognizes that where Americans live and work and go to school 
also has a profound impact on our health. That is why a number of 
provisions in the bill focus on creating healthier communities with 
better access to nutritious foods as well as safe places to engage in 
physical activity.
  A 2007 study by the Trust for America's Health found major savings 
from community-based prevention programs designed to increase levels of 
physical activity, improve nutrition, and reduce smoking rates. This 
study concluded that a national investment of $10 per person per year 
in these kinds of community-based programs could yield net savings of 
more than $2.8 billion annually in health care costs in the first 1 and 
2 years, more than $16 billion savings within 5 years, and nearly $18 
billion savings annually within 10 to 20 years, starting at $10 per 
person per year.
  More generally, this bill aims to give Americans the tools and 
information they need to take charge of their own health. For example, 
it requires large chain restaurants to post basic nutrition information 
on the menu so consumers can make healthy choices. That is in this 
bill. It will start next year.
  The bill also focuses on prevention and public health needs of a 
number of generally overlooked populations, including children, 
individuals with disabilities, Americans living in rural communities, 
and certain ethnic minorities. For many months I have made the case 
that it is not enough to talk about how to expand insurance coverage, 
how to pay the bills--those are important--but it makes no sense to 
figure out a better way to pay the bills for a system that is 
dysfunctional, ineffective, and broken.
  We have to change the health care system itself, beginning with a 
sharp new emphasis on prevention and public health. We also have to 
realize that wellness and prevention must be truly comprehensive. It is 
not only about what just goes on in the doctor's office; it also 
encompasses community-wide wellness programs, about which I just spoke, 
things such as building bike paths, walking trails, getting junk food 
out of our schools, out of the vending machines, making our school 
breakfasts and lunches more nutritious, increasing the amount of 
physical activity our children get, and so much more.
  Some of this is going to be addressed in other bills. For example, 
next year, in the Agriculture Committee, we will be reauthorizing the 
child nutrition bill. That deals with school lunches and school 
breakfasts. We need a major effort there to make our lunches and our 
breakfasts more nutritious for our kids in school.
  Next year, in the committee I chair, the HELP Committee, we are going 
to reauthorize the Elementary and Secondary Education Act, the so-
called No Child Left Behind Act. There are a lot of things we are going 
to be doing on that. I see one of our committee members, the Senator 
from Colorado, Mr. Bennet, in the Chamber, a former superintendent of 
schools, who is going to play a key role in helping get that Elementary 
and Secondary Education Act through and refined and brought up to date 
where we will make some changes.
  But there is one other part of that bill we have to focus on; that 
is, the amount of physical activity kids get in school. I talked many 
times both to Secretary Duncan and, before him, to Secretary Spellings 
about this idea of No Child Left Behind. If we are not going to leave 
kids behind in terms of their writing and their math and their English, 
how about not leaving them behind in terms of their health? Yet recess 
is gone. I saw a statistic this year that said 80 percent of elementary 
school kids in America today get less than 1 hour of physical exercise 
a week in school--80 percent get less than 1 hour a week.
  Mr. President, I do not know about you, but I remember when I was in 
school, in elementary school, we had an hour a day for recess. We had 
15 minutes in the morning, 15 minutes in the afternoon, and a half hour 
at lunch. So there was 1 hour every day, and we had to go out and do 
stuff. We couldn't sit around and play with Game Boys and things like 
that. So we got an hour a day of physical exercise. Well, we need to 
reinvigorate our schools to make sure they get that physical exercise.
  So we have done a lot in this bill to move this paradigm toward a 
health care society rather than a sick care society. There is more to 
do, as I said, in both the Education bill next year and in the 
Agriculture Committee in terms of the child nutrition reauthorization. 
But in this bill we have made a great start. We have laid a great 
foundation. I am just thrilled so many of the wellness and prevention 
initiatives I have championed for so many years are included in this 
bill.
  As I look forward to going to conference, we look forward to working 
with the House to strengthen it even more and to put more emphasis on 
wellness and prevention.
  Just about an hour ago or so, we had a press conference with the 
president-elect of the American Medical Association, Dr. Wilson. I am 
proud of the fact that the American Medical Association has now 
endorsed our bill. As I said at the time, I said the doctors of America 
have examined this bill, and they have made the right prescription: 
Pass it. Pass the health care reform bill.
  But Dr. Wilson, in his statement, made particular note of the 
wellness and prevention programs we have in this bill. He did not say 
this, but I was thinking, when he was talking, that it made sense. 
Doctors want to keep people healthy. They do not want to see people go 
to the hospital. They would rather be working with their patients one 
on one. How can they structure a patient's profile so the patient stays 
healthy, does not get sick so often? That is what Dr. Wilson was 
talking about: letting doctors practice medicine in a way that focuses 
on a person's health and keeping them healthy.
  As President Obama said in his speech to Congress early this year:

       [It is time] to make the largest investment ever in 
     preventive care, because that's one of the best ways to keep 
     our people healthy and our costs under control.

  That was the President of the United States in his State of the Union 
message. Well, President Obama has it right. It is one of the best ways 
to keep our people healthy and our costs under control, and that is a 
big part of this bill. I do not know--I have not listened to every 
speech made by the Republicans on the other side--but I hardly ever 
hear them talk about this, but it is a very important part of the bill.
  So, Mr. President, we are changing the paradigm. We are going to 
extend quality, affordable health coverage to nearly every American. We 
are going to transform ourselves into a genuine wellness society, and 
we are going to give our citizens access to a 21st-century health care 
system, one that is focused on helping us to live healthy, active, and 
happy lives.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Colorado.
  Mr. BENNET. Mr. President, I would like to first thank the Senator 
from Iowa for his leadership over many years, especially on prevention 
and wellness, and to see so much of this bill devoted to that is a real 
testament to his efforts. So I thank the Senator for that.

[[Page 32930]]

  Mr. President, a number of years ago, I left a rewarding job in 
business because I had a chance to lend a hand to my community during a 
very difficult time in Denver. The economy was slow and the city was 
facing a record budget deficit. Our great mayor, John Hickenlooper, 
asked me to come be his chief of staff. It was not a glamorous job, but 
it was rewarding because we got results--not by seeking out what 
divided the people of Denver, who were going through a very rough time, 
but by reaching out time and time again to what the mayor called ``our 
alignment of self-interest.''
  We fixed the city's budget, and then I had the chance of a lifetime 
to become the superintendent of public schools and serve our children 
and the people who work so hard every day to support them. I came away 
from that experience believing that much of the Republican and 
Democratic ortho- doxies relating to public education are essentially 
useless to our children--and maybe worse--and that Washington as a 
whole has absolutely no clue about what is going on in America's 
classrooms.
  So it is fair to say I did not come to Washington with a partisan ax 
to grind. As is probably obvious to everyone around here--for good or 
for ill--I am not a career politician. I did not come here to win 
political points so that someone else could lose. I am not interested 
in that. I am here as the father of three little girls with an abiding 
concern we are at risk of being the first generation of Americans to 
leave less opportunity to our kids and our grandkids than our parents 
and grandparents left us. That prospect is shameful.
  We are not the only Americans who have been working weekends and late 
into the night recently. There are people in small towns and big cities 
all across America doing jobs much harder than ours, who are taking an 
extra shift before Christmas so they can afford that extra gift beneath 
the tree--Americans who are unemployed in this savage economy and still 
trying to make sure the kids know Santa remembered them.
  These same people are reading their papers and watching their 
televisions wondering what in the world we are doing here in 
Washington. All they see are talking heads yelling at each other on 
cable news, needless partisanship paralyzing their government, and even 
people praying that Senators will not be able to make votes.
  I am not naive about politics, but I expected more. I will vote for 
health care reform because it is a step in the right direction. But I 
will not go home and defend the actions of a Washington that is out of 
touch, a Washington that is more interested in scoring political 
points, more interested in the 278 health care lobbyists who used to 
work for Members of Congress than it is in what our constituents have 
to say, a Washington that is more concerned with the millions being 
spent by big insurance companies than the thousands of dollars being 
lost by working families who are struggling to pay for coverage.
  Columnists opposed to reform have criticized me for saying that I am 
willing to lose my seat to enact meaningful health care reform. Now I 
am being asked why I did not negotiate a special deal with leadership. 
In fact, there was a report this morning criticizing me because the 
National Republican Senatorial Committee was rejoicing that I did not 
ask for special favors. Only in Washington would someone be attacked 
for not negotiating a backroom deal. Just because others choose to 
engage in the same tired Washington rituals does not mean I have to.
  So I have a message for the columnists, the political professionals, 
and those back home: I am not happy about the backroom deals. I am not 
happy that the public option was held hostage by people in our own 
party. I do not support rewarding delay with special deals. I will let 
others justify their vote and their tactics.
  As for me, I am voting to provide coverage to 840,000 uninsured 
Coloradans, voting to extend Medicare for our seniors and provide free 
preventive care for everyone, voting to close the prescription drug 
loophole and provide tax cuts to small business, voting to make health 
care more affordable and eliminate exclusions based on preexisting 
conditions, voting for health care reform that is fully paid for.
  The people in my State and in our country deserve better than a 
politics that cares more about lobbyists and talk show hosts than the 
people we represent. I am committed to delivering on that despite what 
the political experts have to say. And, in the end, when the dust 
settles and the stories focus more on substance and process, I am 
confident Coloradans will see it the same way.
  I also commit to the people of Colorado and the people of this 
Chamber that I will do everything I can to make sure this bill is fully 
paid for. That is why I submitted an amendment that will ensure that 
health care will help pay down the deficit by forcing Congress to make 
adjustments if reform does not meet the cost estimates we have 
projected.
  I urge my colleagues and the leadership in the Senate to see to it 
that this amendment is included in the conference report. If not, I 
will fight to get it passed on its own. I believe so strongly in this 
because everyone here knows that keeping things the way they are is no 
longer acceptable.
  When I first started in the Senate, 800,000 Coloradans were without 
health insurance. That number has grown by 40,000 in the months we have 
debated this bill. On average, 111 Coloradans have lost their health 
insurance every single day. This number will only get worse if we do 
nothing. Our State has spent $600 million in the last year alone on 
uncompensated care.
  Colorado's working families suffered double-digit health insurance 
cost increases year after year for the last decade. Many families have 
made terrible sacrifices--no longer investing in their children's 
futures, saving for a home, or carrying crushing credit card balances--
all to pay for health care.
  Small businesses pay 20 percent more for health insurance than large 
businesses do just because they are small.
  I think back to the Coloradans who shared their stories with me 
during this debate.
  I remember Bob and Deb Montoya of Pueblo. They were torn between 
providing health care for their small business employees and keeping 
their business afloat. Last year, their business paid out $36,000 to 
cover two families and one employee. They could not afford to give 
their other 12 employees health care or they would be literally forced 
out of business. So they dropped coverage for the 12 employees to keep 
their doors open.
  Hollis Berendt owns a small business in Greeley and told me about her 
daughter Abby who graduated from Colorado State University in 2004 and 
found a job in New York with a large company. Her daughter's company 
made her wait a year before she was eligible for health insurance, and 
during that time Abby was diagnosed with ovarian cancer. Hollis took 
out a second mortgage to pay for her daughter's bills and told me:

       This experience brought to light, all too clearly, how 
     close we all are to losing everything due to a health issue.

  I have spoken here before about a young boy named Alex Lange. Alex's 
parents' insurance company refused to cover Alex because he was 4 
months old and 17 pounds. They said he had a preexisting condition, at 
4 months, of obesity.
  Then there was 2-year-old Aislin Bates, whose parents' insurance 
company denied her coverage because she was underweight. One child too 
big, the other too small. Today in America, you have to be just right 
to get insurance.
  There was Peggy Robertson of Golden, CO, who was told she could not 
receive coverage unless she was sterilized, Mr. President. She came and 
bravely testified in Washington about the need for reform. There was 
Matthew Temme of Castle Rock, who could not receive coverage because 
his wife was pregnant, even though she had her own health insurance.
  The sad thing is, there is nothing unusual about these stories. None 
of these people were trying to cheat or game the system. They were 
trying to

[[Page 32931]]

gain some peace of mind, some stability in their lives and, instead, 
they wasted weeks of their lives fighting against insurance company 
bureaucracy and mounting bills.
  We have debated health care reform for over a year. Some have been 
working on these issues for decades. Killing health care reform under 
the disguise of starting over is not an option. We cannot wait until 
after the next election. We cannot wait until our economy recovers or 
until we have come home from Afghanistan to deal with our broken health 
care system.
  Now standing so close to the finish line, it is completely 
understandable that some Americans doubt whether this bill will improve 
their situation. They understand we cannot live with the current 
system. But they are also deeply concerned about our capacity to make 
it worse.
  The special interests are using tried-and-true tactics that have been 
employed over and over across the decades to prevent reform: phone 
calls to scare seniors, direct mail to scare those already covered, 
television ads to scare just about everyone else, and opponents of this 
reform in this body are trying every delay tactic permitted by the 
Senate rules.
  Amidst all this, there is still a reason to hope. After almost a 
century of trying, the Senate is very close to finally passing a 
meaningful health care reform bill, a piece of legislation that while 
not perfect, represents a substantial step forward from business as 
usual. We have a bill that does three important things: It saves money, 
it saves lives, and it gives families a fighting chance in their 
relentless struggle with health insurance companies.
  This bill will save money. It reduces the deficit by $130 billion 
over the first 10 years, according to the nonpartisan Congressional 
Budget Office, and is projected to reduce the deficit by 10 times 
that--up to $1.3 trillion--in the second decade. We will save $\1/2\ 
trillion by improving the way we deliver services to our seniors. These 
savings will prevent Medicare from going broke in 7 years by extending 
the life of the Medicare trust fund.
  This bill will save lives. It will extend health insurance coverage 
to 31 million Americans who don't have it today. Over 90 percent of 
Americans will have health insurance coverage, the highest percentage 
in the history of the United States. For Colorado, that means over 
840,000 people who don't have insurance will now have access and 
another 300,000 people who have insurance in the unstable individual 
market will be able to get affordable coverage through the new health 
insurance exchange.
  The Senate bill makes preventive services, such as breast cancer and 
colorectal cancer screening, available without copayments. Now 
mammograms and colonoscopies, which can cost between $150 and $200, on 
average, will be free as well for seniors--half a million seniors in my 
home State alone. This means catching diseases earlier, promoting 
wellness, and saving millions of lives.
  For our Nation's working families, this bill will also rein in the 
worst practices of private insurance companies. They will have to 
commit to covering patients instead of gouging them for excessive 
profits and overhead. Starting in 2011, if an insurance company doesn't 
give you value for your dollar, they will have to refund you back the 
difference. They will not be able to impose arbitrary lifetime limits 
on consumers and punish you just for getting sick or deny you insurance 
because of a preexisting condition. The newest Senate bill does more to 
contain costs, more to demand accountability and transparency from 
insurance companies, and more to give consumers a better choice.
  For my home State, in particular, I am glad the bill addresses other 
critical areas. This reform does more for small business and small 
business workers than ever before. Small business tax credits will 
begin next year, giving eligible businesses a tax credit for 6 years to 
purchase health insurance for their employees. We have extended tax 
credits for small businesses, allowing more than 68,000 small 
businesses in Colorado to buy health insurance.
  This bill makes a significant investment in Medicare payments to 
rural areas. When I first joined the Senate, my first piece of 
legislation called for a deficit-neutral reserve to address the 
differences in Medicare payments between urban and rural areas. This 
Senate bill recognizes the geographic differences between rural and 
urban areas and makes sure providers in rural Colorado that provide 
higher quality at lower cost receive higher Medicare payments.
  This bill also delivers on its promise to seniors. It doesn't use a 
dime of the Medicare trust fund to pay for reform and does not cut 
guaranteed benefits. That is why, on the first day of the health care 
reform debate, I introduced an amendment that would make sure seniors 
will still see their guaranteed benefits, such as hospital stays and 
prescription drug coverage, no matter what changes we make in health 
reform. It was the most bipartisan piece of legislation we have had 
this year, with 100 Senators agreeing health reform would not take away 
guaranteed Medicare benefits for seniors. For Colorado, that means half 
a million Medicare beneficiaries will continue to have their guaranteed 
benefits protected and preventive services free of charge through 
health reform.
  I am very pleased Majority Leader Reid included a version of a piece 
of legislation I wrote based on the work in Mesa County, home of Grand 
Junction, CO. Currently, one out of every five Medicare patients who is 
released from the hospital in this country winds up back in the 
hospital in the same month they were released but not in Mesa County. 
They have reduced the readmission rates at the hospital to about 2 
percent, compared to the national average of 20 percent. That is 12 
million patients who aren't receiving the care they need. In Mesa 
County, they have lowered readmissions by creating a transitional model 
that makes sure that when patients leave the hospital, they do so with 
a coach. That coach helps them go from the emergency room to their 
primary care physician, their mental health provider, making sure they 
get the care they need over a period of time, making sure they don't 
forget their prescriptions, and making sure they have the guidance they 
need to take responsibility for their own care. I am pleased the Senate 
bill compensates and reimburses hospitals and providers that set up 
models such as the one in Mesa County that actually saves money.
  On another note, I wish to thank the Presiding Officer and my fellow 
freshmen. Together, we worked hard to introduce a package of amendments 
to further contain costs and make our system more efficient. As I 
traveled throughout Colorado on the August break, I heard from doctors 
and nurses who told me repeatedly all they wanted to do was work with 
patients, while all the government was doing was making them fill out 
one form after another. When I came back, I was determined to do 
something to help cut the red tape and bureaucracy for these people so 
they could spend more time with their patients. That is why, as part of 
the freshman package, I introduced an amendment to put an end to 
multiple forms, confusing codes, and unnecessary paperwork that burden 
providers. If health plans don't follow the rules, they will suffer 
financial penalties. Our health care workers deserve better, and this 
amendment gives them back time to spend with their patients.
  Our freshman package rewards and emphasizes efficiency: one form to 
fill out, not 10; less red tape; fewer bureaucrats; a system that makes 
sense. Thanks to the leadership of the Presiding Officer, that package 
was endorsed by the Business Roundtable, the AFL-CIO, and the Consumers 
Union--proof that at least off this floor, there are still people from 
all different points of view who are willing to work together.
  This bill also makes progress in the area of tort reform. It includes 
language I worked on with Senators Baucus, Carper, and Lincoln to 
create a State grant program for States to develop, implement, and 
evaluate alternatives to tort litigation for medical

[[Page 32932]]

malpractice claims. The purpose of these grants is to limit litigation 
while preserving access to courts for patients and promoting strategies 
to reduce medical errors.
  I know many in this Chamber take issue with one particular part of 
this bill or another. I have my own issues with the bill. I am one of 
many who have expressed their strong preference for a public option. 
But I urge my colleagues to consider how much good this bill can do for 
the American people--those with skyrocketing health care costs, small 
businesses forced with the impossible choice of helping workers keep 
their coverage or even just maintaining their business. To have the 
nonpartisan experts at the Congressional Budget Office validate that in 
the second decade we will have cut health care costs by up to $1.3 
trillion and that we will reduce the rise in costs of Medicare from 8 
percent in the next two decades to 6 percent in the next two decades, 
while covering 31 million insured Americans, is truly groundbreaking.
  We know what more time elapsing without fixing this system means for 
Colorado's working families and small businesses. It means more double-
digit premium increases, less time to fix Medicare before it goes 
bankrupt in 2017, and more names added to the rolls of the uninsured. 
It means another big win for the special interests, more people denied 
coverage for preexisting conditions, and more small business employers 
will have to make impossible decisions about covering their workers or 
keeping their doors open.
  So let's reject business as usual. Let's look at the promise of this 
Senate bill as a whole. Let's put the pettiness, scare tactics, and 
obstruction aside. Reform is what is needed to control costs, give 
people more choice, and provide support for our small businesses. This 
package will reduce our deficit, and it does so by reforming the way we 
provide health care.
  We have much to do. Even before we were in the worst recession since 
the Great Depression, during the last period of economic recovery, 
working families' incomes in this country actually declined, the first 
time in the history of the United States, the first time our economy 
grew and left the middle class behind. At the same time, in my State of 
Colorado and in all States across the country, the cost of health 
insurance rose by 97 percent and the cost of higher education in my 
State went up by 50 percent. Finally, because of the short-term 
politics practiced around here, we now have an annual deficit and long-
term debt that is cheating our children and constraining our choices.
  We still have a lot to do to live up to the legacy that our parents 
and grandparents left us. It has taken me less than a year to 
understand that Washington still doesn't get it. I know we can do 
better, and despite so much evidence to the contrary, I believe we 
will.
  I believe we will because, in the end, the national creed that each 
generation of Americans has fought for and fulfilled--the idea 
expressed in our Constitution that our responsibility lies not just 
with ourselves but to our posterity--is so much more powerful than the 
trivial politics that animate so many of the charges and countercharges 
that ricochet around this building.
  It is for this reason I urge my colleagues to come together and 
support this meaningful improvement in our health care system.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Ms. KLOBUCHAR. I ask unanimous consent to yield myself 10 minutes.
  The PRESIDING OFFICER. The Senator is recognized.
  Ms. KLOBUCHAR. Mr. President, late last night, as my colleagues are 
aware, the Senate took the important step to move forward on health 
care reform. After all the work, the debate that has gone on for this 
entire year, we owe the American people a vote on this issue. We can't 
afford to ignore this situation anymore.
  I know some of my colleagues on the other side of the aisle have been 
talking about a lack of debate. I think anyone who has turned on C-SPAN 
for the last few months will tell you there has been a lot of debate--
not only that, a number of Republican amendments were actually included 
in the original bill, the HELP Committee bill. When it came out, I 
believe it was something like 130 amendments that were included that 
came from their side--and the Finance Committee as well.
  I remember the first bipartisan meeting we had on health care reform 
was something called Ready to Launch that the Finance Committee put 
together. I remember Senator Whitehouse and I were there. It was 
literally a year and a half ago. So many of the ideas that are now 
incorporated in this bill that Senator Bennet from Colorado just so 
eloquently went through are in this bill, so many of the bipartisan 
ideas to kick off cost reform, to start rewarding high-quality care, to 
start bringing down those costs in a way that gives us the high-quality 
care.
  We all know that rising costs are not sustainable. If we don't act, 
these costs are going to continue to skyrocket.
  So what was the vote about last night? The vote last night was to say 
we are not going to put our heads in the sand anymore. We are not going 
to keep letting these costs go up.
  Ten years ago, the average family was paying $6,000 a year for their 
health insurance. Now they are paying $12,000 a year. Well, 10 years 
from now, if we don't do anything about this, they are going to be 
paying $24,000 to $36,000 a year for their health insurance. Just look 
at these numbers. Look at where we are. In 1999, a single person was 
paying about $2,100 for their health care. They were paying for a 
family, $5,790 for their health care. Where are we now? Last year, in 
2008, a single person was paying $4,700 for their health care and then 
a family was paying $12,680. Especially during this difficult economic 
time when wages haven't been going up, people have been losing their 
jobs, cutting back on their hours, and look what their health care 
costs have been. It has been a higher and higher percentage of their 
family budget, a higher and higher percentage.
  At the same time, health care expenditures are going up and up and 
up. In 1995, we were spending something like $12 billion and now it is 
way up to $2.5 trillion. This is the kind of money we are talking about 
when we look at why we have to do something to bend the cost curve. 
When people at home hear this term ``cost curve'' and they don't know 
what it means--well, this is exactly what it is: The cost curve has 
been going up and up and up for health care in America.
  So $1 out of every $6 spent in our economy is on health care. Over 20 
percent of our economy, by 2018, we believe, will be spent on health 
care. American families can no longer afford it.
  Who has been taking it the worst? Small businesses. They are paying 
20 percent more than large businesses for their health care. In a 
recent survey, nearly three-quarters of small businesses that did not 
offer benefits cited high premiums as the reason.
  These are little companies such as Granite Gear up in northern 
Minnesota and Two Harbors. I went up there and visited them. They are a 
thriving little company. They now have 15 employees. They are making 
backpacks for our Nation's soldiers because they make such high-quality 
backpacks. Do you know what the man who started that company told me? 
That if he had known how much his health care would cost with his 
family of four--he did not have kids when he started the business--he 
would not have started it today. He is paying $24,000 in Two Harbors, 
MN, for a family of four.
  This is what it really means when you look at the numbers. Inflation 
usually raises the cost of most goods and services between 2 and 3 
percent a year. What have health care premiums been doing? Health care 
premiums have been going up close to 8 percent a year, and that is an 
increase Americans simply cannot afford.
  What does this bill do? I was listening to some of the commentary and 
taking part in it myself over the weekend. There seems to have been a 
lot of talk about these delayed benefits. Why don't we talk about the 
benefits that

[[Page 32933]]

are taking place right when the President signs this bill, within the 
first year of this bill?
  The first thing is, if your kid loses their coverage because 
something goes wrong--if they get diabetes or if they have some 
childhood disease--guess what. They are going to be able to get health 
care. There is no longer a ban on preexisting conditions immediately, 
and then in later years that applies for adults as well but immediately 
for kids.
  Immediately, by 2011, within the first year of the bill, our seniors 
are going to be covered in that doughnut hole for their prescription 
drugs. So many of them for so long--I know my own mother would complain 
about this doughnut hole where they fall off a cliff and are not able 
to pay for their drugs because they do not have enough money. That will 
be covered.
  A number of the small business tax credits take effect by 2011. These 
are real benefits for the people of this country--real benefits.
  The thing I care most about in this bill which Senator Bennet 
discussed is this idea of getting our money's worth for our health care 
dollars. What does this bill do? This new bill--we have taken a lot of 
the good from the original bill and made things even better: $132 
billion off the deficit in the first 10 years and in the next 10 years, 
$1.3 trillion off the deficit. That was the most important thing to 
people in my State when I went around. They said: We want to get rid of 
these preexisting conditions, we want to make things better so we have 
better health care, but we want to make sure we do something about the 
deficit, start doing something about costs.
  As you know, Mr. President, Minnesota is a mecca for health care. We 
have one of the high-quality, cost-efficient, low-cost States in the 
country. In fact, when we look at some of the numbers, one of my 
favorite ones--and maybe this will be the last time I will say this 
before the end of the year--is Mayo Clinic. They did a study out of 
Dartmouth, and they looked at what Mayo did with chronically ill 
patients. What they found was this: If other hospitals in the country 
simply use the same high-quality care Mayo uses--bring the family in, 
talk to them about what the care should be for the patient--they talk 
to the patient and then figure out what is the best course. They work 
as a team, like a quarterback with a team working with that 
quarterback. They do not have 20 specialists falling all over each 
other; they work as a team. What this study showed was this kind of 
health care for that subset of chronically ill patients in the last 4 
years of their lives, the quality ratings were sky high for the Mayo 
Clinic. The families felt good about how their loved ones were treated.
  What Dartmouth found is if all the hospitals in the country followed 
the same protocol, we would save, for this subset alone, $50 billion 
every 5 years in taxpayer money, giving patients that Mayo health care, 
giving them high-quality health care. It is counterintuitive to people. 
If you go to a hotel and you pay the most, you are going to get the 
best room with the best view. That has not been the same in American 
health care. In fact, there is an inverse relationship.
  I see my friend from Ohio. Ohio has the Cleveland Clinic, and there 
is Geisinger. Those places that offer high-quality care also tend to 
have some of the lowest costs.
  Those are the incentives we are putting in this bill--incentives for 
accountable care organizations, incentives for that integrated care I 
talked about instead of people running around with x rays to 20 
specialists, getting charged every single time, but then one specialist 
does not know what the other specialist is doing. They don't know what 
kind of drugs you are allergic to when you go in for surgery. This is 
because there is no communication. This bill promotes that integrated 
care where you put the patient in the driver's seat so they have their 
pick of a doctor. That is what we want--bundling of payment so you 
start rewarding outcomes instead of the number of tests and procedures.
  My favorite example of this came out of the Geisinger Clinic in 
Pennsylvania, where they said: We are not that happy with how we are 
treating diabetes patients. So instead of having everyone wait to see 
an endocrinologist, a doctor, we are going to have some of the routine 
cases see nurses, and the nurses will report to the doctors, and the 
patients will be happier because they will be able to see a nurse more 
often. The most difficult cases will be treated by endocrinologists.
  They did that for about a year and looked to see what the results 
were. Guess what. The patients were much happier because they were able 
to communicate one-on-one with the nurse. The doctors were able to 
handle the most difficult cases and monitor the other cases. They saved 
$200 a month per patient with this kind of system. Higher quality care 
and better patient outcomes.
  What does our system do when they see this kind of smart, cost-
effective result for the doctors and for the system and for the 
taxpayers? They actually are told: You get punished for this under our 
system. You are going to get a lot less money if you do something like 
this. That is what I am talking about.
  On hospital readmissions, we could save $18 billion a year. If you go 
in the hospital and you are treated, you want to go home. You don't 
want to go back into the hospital because someone made a mistake or 
they gave you an infection. Let's provide incentives--that is what this 
bill does--so that we reduce those hospital readmissions, make life 
better for the patient and at the same time reduce taxpayer money. That 
is what this bill is about.
  Right now, fraud is $60 billion. I don't think anyone would believe 
this. A senior who just depends on Medicare, right--we have to tell our 
seniors today that $60 billion a year is wasted on Medicare fraud, 
going to con men, going to people who set up storefronts and they get 
fake checks and they are not even real. That is where the money is 
going right now--down the tube, siphoned off by fraudsters. What this 
bill does is give the tools to improve that situation so that will not 
happen anymore.
  That is what we are doing with this bill. It is about reducing costs, 
it is about raising quality, and it is about saving Medicare so it does 
not go in the red by 2017, giving it 10 more years and beyond because 
of the delivery system changes.
  I am proud to support this bill. We continue to work for reform. As 
you know, this is not just an end, this is a beginning. There will be 
more work to do in the future, but we cannot put our heads in the sand. 
We have to vote on this bill. We have to get this done.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Ohio.
  Mr. BROWN. Mr. President, it has been said that a cynic knows the 
price of everything and the value of nothing. I spent, as we all have, 
as the Senator from Minnesota has, as the Presiding Officer has, the 
last 4 weeks listening to my colleagues come to the Senate floor to 
describe health reform legislation that bears no resemblance to what is 
actually before us. They take liberties with the cost of the bill. They 
seem to have no concept of the value of health care to a family who has 
it and to a family who does not have it. I guess they believe it is not 
important for us to get this done, it is not important for other 
Americans to have affordable health insurance.
  My colleagues are not at risk of losing their coverage. They can 
afford the health care they and their families need. So what is it to 
them if another 14,000 people lose their insurance every day? Mr. 
President, 390 people every single day in my State lose their 
insurance. What is it to them if people with preexisting conditions 
cannot get coverage, if women are overcharged for insurance, if the 
self-employed cannot afford the outrageous premiums they are charged, 
if too often American small businesses pay more for health coverage 
than they earn in profits? What is it to them?
  I have listened as Republican Senators have come to the Senate floor 
day after day to tell tales about health

[[Page 32934]]

care reform and try to manipulate public opinion by any means possible. 
I hear them mostly stalling: Slow down, not yet. They have done it 
since the Gang of 6 in the Finance Committee met in June. No, actually 
they had begun to stall even before that when the Finance Committee and 
the HELP Committee began their deliberations, informal deliberations.
  What they forget or what they do not want to think about, perhaps, is 
that every day they stall, 390 people from Galion to Gallipolis, from 
Buckeye Lake to Avon Lake, from Ashtabula to Cincinnati, 390 people in 
my State lose their insurance every day. Every day, we see 14,000 
Americans lose their insurance, and 1,000 Americans die every week 
because they do not have insurance. One thousand Americans die every 
week because they do not have insurance, and on the other side of the 
aisle they say: Slow down. What is the rush? Why do we have to move 
into this?
  They forget or maybe they just do not want to hear that a woman with 
breast cancer is 40 percent more likely to die if she is uninsured than 
if she has insurance. Women with breast cancer are 40 percent more 
likely to die if uninsured than if they have insurance. Yet they 
continue to say: Slow down.
  I wish my friends on the other side of the aisle would actually meet 
some of these people who do not have insurance. Let me put a human face 
on this, if I can. Let me share three letters from Ohioans. I have come 
to the floor since July day after day reading letters from people 
directly affected by this health insurance situation, if you will. In 
most cases, these are people who were happy with their health insurance 
a year ago, and something happened in their lives--they got laid off 
and lost their insurance; had a child with a preexisting condition for 
whom they could not get insurance; maybe they got sick and the cost of 
their health care was so high that the insurance industry cut them off, 
simply eliminated their coverage. Let me read a couple of these.
  Marie from Hancock County, OH:

       My husband and I both have preexisting conditions and are 
     stuck paying $1,300 a month for health insurance. He has been 
     out of work for 2 years and we are living off the money that 
     we got when we sold our house. We are afraid to go without 
     insurance. We are in a fix and in our late middle ages and 
     find ourselves watching our retirement savings go down the 
     drain. Please fight for us and others like us.

  Think about that. Does anyone in this Chamber, does anyone who comes 
to work as a Senator or down the hall as a Congressman--can any of us 
really understand what this couple is all about, this couple from 
rural, smalltown Ohio paying $1,300 a month? How are they paying for 
their insurance? They sold their house so they could pay for their 
health insurance. They are in their late middle ages. I am guessing 
they are probably in their late fifties, early sixties. They are not 
eligible for Medicare.
  So many people say to me through these letters and through my 
meetings and discussions and when I am traveling around my State: I am 
63. I only have 2 years before Medicare because I trust Medicare. It is 
stable, predictable. It will be there for me, and it will help.
  Instead, Republicans in this body, all 40 of whom even voted against 
the bill last night--40 said: Stop. Don't even move forward on this 
bill. Do any of those 40 really understand people such as Marie from 
Hancock County? Do any of them understand? Do any of them understand 
that 390 people are losing their insurance every day in just one State? 
Do any of them understand that 1,000 people a week are dying in this 
country because they do not have insurance? Do any of them understand, 
any of the Members of Congress, the House of Representatives or the 
Senators, the 40 Senators who said no and stall and stall, saying: Not 
yet; can't do this yet; have to slow it down. Do any of them understand 
that a woman with breast cancer is 40 percent more likely to die if she 
does not have insurance than if she does?
  Charles from Cuyahoga County, the Cleveland area, writes me:

       The hands-off-health-care people claim that many Americans 
     are very satisfied with their own health insurance. I am one 
     of those. I have Medicare. But I don't believe their 
     implication that health care reform is not needed. I think if 
     you were to really ask those lucky people who were somewhat 
     satisfied with their plan--a great majority would say they 
     support reform that would benefit everyone.

  Charles understands. He is on Medicare. He understands the stability 
and predictability of the Medicare system.
  I might add parenthetically that my Republican friends, all 40 of 
whom last night said: Stop, slow down, stop, slow down, all 40 of them 
understand that their party overwhelmingly opposed the creation of 
Medicare. When they had a chance, they tried to cut it and privatize it 
in the nineties. Then when President Bush was sworn in, with Republican 
leadership in the House and Senate, they moved forward on their 
giveaway to the drug companies and insurance companies in their 
attempts to privatize Medicare. Now they say they are all for Medicare.
  Understand, Charles knows what this bill is going to do. It is going 
to strengthen Medicare. It is going to lengthen the lifespan of 
Medicare. It is going to give free physicals, once-a-year checkups, 
colonoscopies, and mammograms for people on Medicare, and it is going 
to close the doughnut hole so fewer people will have to pay so much out 
of pocket.
  Last letter. Raymond from Delaware County:

       My wife and I had to drop our coverage because it cost us 
     $30,000. The country needs reform that bars insurance 
     companies from denying coverage or charging higher premiums 
     on the basis of preexisting conditions. Health reform is the 
     right solution for the people of Ohio.

  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BROWN. I yield the floor.
  The PRESIDING OFFICER. The Senator from Wyoming is recognized.
  Mr. BARRASSO. Mr. President, I just heard my colleague, the Senator 
from Ohio, say: I wish some of my colleagues on the other side of the 
aisle would understand families who don't have insurance.
  I practiced medicine for 25 years, taking care of families in the 
State of Wyoming. During that time, I took care of all patients, 
regardless of their ability to pay. I will tell you, I believe, as a 
physician who practiced medicine for 25 years--and as someone whom the 
Obama administration has decided to completely ignore, as he did the 
other Senator of this Chamber who is a physician--that I know 
specifically and personally about what happens to families who lose 
their insurance. My colleague and I know specifically what happens to 
families who are on Medicaid, a health care program which my colleague 
who is now leaving the Chamber after asking if anyone in this body 
understands people without insurance but not staying to hear the 
discussion for the next hour--making statements and then leaving--I 
understand those families. I understand the families on Medicare, I 
understand the families on Medicaid, I understand the families without 
insurance, I understand the families worried about losing their 
insurance, I understand about the families worried about disease.
  My colleague from Ohio said: Do people understand women with breast 
cancer? Well, my wife is a--
  Mr. BROWN. Will the Senator from Wyoming yield?
  Mr. BARRASSO. Regular order, Mr. President.
  Mr. BROWN. I just wished to let the Member know I am still in the 
Senate.
  Mr. BARRASSO. My wife was a breast cancer survivor, and her breast 
cancer was discovered in her forties by a screening mammogram. It was 
that screening mammogram that saved her life because the cancer had 
already spread. It had already spread to a lymph node. She had three 
operations, two bouts of full chemotherapy, radiation--35 treatments 
and all--all--because of the screening mammogram that saved her life. 
Yet because of this bill that was brought to the Senate floor--with the 
government knowing better than the rest of America, knowing what health 
care ought to be given and shouldn't be given--all of a sudden what we 
see is the government knows best, people don't know--her life would 
have been lost because she is one of those 1,900.

[[Page 32935]]

  So I understand, having practiced medicine, having lived that life as 
a physician--taken care of people without health insurance and on 
Medicaid and Medicare and those worrying about losing their insurance 
when they lose their job--the implications. Yet I took care of all of 
them, as did all my partners. We dealt with all these people, trying to 
help each and every one of them, regardless of their ability to pay. It 
is why we need health reform in this country that actually works on 
availability of care, affordability of care, access to care, and 
quality care. This bill that I voted against last night doesn't address 
the needs of the country. It fails time and time again.
  The President made a number of promises--a number of promises--to the 
people of this country. He said people would see their insurance 
premiums drop by $2,500. Instead, the budget officers say: Oh, no, it 
is going to go up $2,100 for a family. Has the President not read the 
bill, not read the responses that have come from the Congressional 
Budget Office? Does he not see the difference there of $4,600 per 
family?
  The President said this wouldn't add a dime to the deficit. Well, it 
is going to add a lot of dimes to the deficit. This is going to add $1 
trillion to the deficit. He said: Oh no, will not at all. Yet they 
didn't do the doctor fix--the Medicare doctor fix. Now the Speaker of 
the House says: Oh, we will handle that in January or February for $250 
billion, since they are not going to pay for it here.
  The President said: Taxes will not go up on anybody making under 
$250,000 for a family. There are a dozen taxes in the bill that will be 
passed on to the American people. Now any teenager who goes to a 
tanning salon is going to get taxed 10 percent. I don't think any of 
those people are making over $250,000 apiece.
  The President said: People will not lose their coverage. Oh, they are 
going to lose their coverage. Many will lose the coverage they have, 
coverage they like, because they have cut 11 million people on Medicare 
Advantage--a program people like, a program my patients like. People 
whom I have taken care of like it because there is actually an 
advantage to the program. It is a program that deals specifically with 
preventive care. It is coordinated care. That is what happens with 
Medicare Advantage. The President doesn't like. They will lose their 
coverage.
  Of course, the President said we wouldn't see any cuts to Medicare. 
Yet the bill says $500 billion of cuts to Medicare for the seniors who 
depend upon Medicare.
  The President said we would have an open, honest debate. He said C-
SPAN would be there covering the debates. Those of us with the most 
experience--the two physicians, with 50 years in the practice of 
medicine and taking care of families in this country--were completely 
excluded--completely excluded--even though we offered to go to the 
White House and read the bill with the President.
  So what do we have? What is the verdict of the American people on the 
vote that was taken in the dark of night--at 1 a.m. in the morning--a 
Monday morning vote, taken at 1 a.m. so the American people, hopefully, 
according to the Democrats, would be asleep and not see what they were 
doing to the American people? The verdict is the American people are 
overwhelmingly opposed--opposed--to the bill the Senate last night 
voted 60 to 40 on cloture and decided to move ahead on.
  The deals in the bill are absolutely astonishing: $100 million for a 
hospital in a State we still can't identify and no one is claiming, a 
payoff to one State, a payoff to another State, and then the cuts in 
Medicare for our seniors who depend on Medicare, a program that is 
going to go broke in the year 2017--not to save Medicare. Instead of 
saving Medicare, to start a whole new government program.
  I see my colleague from the State of Tennessee is standing, and he 
has worked closely with people on Medicare in his home State. He is 
familiar with that and with Medicaid and he knows how difficult it is 
for patients to get to see a doctor. With the cuts in Medicare, it is 
going to make it harder for those hospitals to stay alive and open in 
your community, and for patients to get the kind of care they need.
  So I would ask my friend from Tennessee: Are there concerns you have 
about the cuts to Medicare and how they are going to impact on the care 
of people in your home State?
  Mr. ALEXANDER. I thank the Senator from Wyoming and appreciate his 
leadership on this bill. It is of tremendous value to have within our 
body two practicing medical doctors to help us interpret the effect of 
this bill, which affects all 300 million Americans so dramatically.
  We find, when we discuss this bill with our colleagues on the other 
side of the aisle, we sometimes become exasperated with one another 
because it seems like they are talking about one set of facts and we 
are talking about another set of facts. So what I would like to do is 
take a moment and talk about Medicare.
  If anyone is watching our debate, you hear the Democrats talk about 
three things: We are saving Medicare, we are extending its length, and 
you hear Republicans say they are cutting Medicare. So who is right?
  Well, let me tell you why we talk about Medicare cuts. Medicare, of 
course, is a government program which 40 million seniors depend on. We 
all pay into it, and then when we get to be of a certain age we depend 
upon it for our medical care. For many Americans, it is very important. 
It was established with broad bipartisan support in the 1960s.
  What are the proposals that have to do with Medicare? Well, basically 
half this health care bill is paid for by reductions in the growth of 
Federal spending for Medicare. Those are Medicare cuts. Who says they 
are? Well, the President of the United States, for one, says we will 
have no deficit from this bill. So the way we are going to do that, for 
this bill, which the Congressional Budget Office figures show us will 
cost $2.5 trillion over 10 years when fully implemented, is basically 
paid for one-half by Medicare cuts and one-half by new taxes. Give the 
Democrats credit for that, that helps to avoid a large part of the 
deficit. The rest is done by sending a huge bill to States to help pay 
for another big government program called Medicaid, but I will leave 
that to the side for a moment.
  The Medicare cuts which are reductions in the spending for Medicare, 
are $466 billion over the first 10 years and over a fully implemented 
10 years it is about $1 trillion in Medicare cuts. That is money coming 
out of the Medicare Program and going somewhere. Where does it go? 
Well, it goes to start a new program.
  What is wrong with that? Well, one thing wrong with it is the 
trustees of Medicare say that there is already more money coming out of 
Medicare than is being paid in, and by the year 2015 or 2017 it will be 
insolvent. That means going broke. These aren't Republican trustees or 
Democratic trustees, these are the men and women whose job it is to 
report to the Nation on the condition of this program that takes care 
of 40 million people and their medical care.
  Already we see that the Medicare Program is under some stress. The 
doctors, for example, who serve Medicare are only paid about 83 or 84 
percent as much as doctors who serve patients with private health care. 
As a result of that, we have to come along year after year and 
appropriate more money to reimburse doctors who serve Medicare 
patients. If we do not do that, they will not be serving Medicare 
patients, and Medicare will become similar to Medicaid, the program for 
low-income Americans, where about 50 percent of doctors will not take a 
new Medicaid patient. It is akin to telling somebody: I am going to 
give you a ticket to a bus line where the bus only runs about half the 
time.
  So what the Democrats are saying to us is that by taking $1 trillion 
out of Medicare over 10 years when fully implemented, and there is no 
dispute about that amount of money, and spending it to pay for this new 
program that is somehow good for Medicare and

[[Page 32936]]

for the seniors who depend upon it. I mean, they are suggesting we 
believe if you take $135 billion from hospitals and $120 billion from 
the 11 million seniors who participate in Medicare Advantage and $15 
billion from nursing homes and $40 billion from home health agencies 
and $7 billion from hospices, that somehow that is good for seniors.
  Perhaps it could be, if all that money were put back into Medicare; 
if the money were taken from grandma and spent on grandma. But no, this 
money is taken out and spent on a new program. The Director of the 
Congressional Budget Office--not a Republican, not a Democrat, the 
nonpartisan Director said, for the 11 million on Medicare Advantage 
that one-half of their benefits will be diminished. That is what he 
said about these cuts.
  Even when it is all said and done, we completely leave out the $\1/4\ 
trillion that we need to appropriate to pay the physicians to serve 
Medicare patients. Because if we don't, their payments are going to be 
cut by 21 percent next year and fewer of them will see Medicare 
patients. We have already heard the Mayo Clinic, for example, is 
beginning to restrict some patients on Medicare because they lost $840 
million serving Medicare patients last year.
  I have taken a few moments to talk about Medicare. That is just one 
thing wrong with this bill. But when you hear the other side say they 
are helping Medicare, and if you listen to what I said about how can 
you take $1 trillion out of the Medicare Program--which is going 
broke--when it is fully implemented over 10 years and claim you are 
helping Medicare by starting a new program, I don't think that is 
possible. That is the source of the great concern on our side of the 
aisle about this bill on that one issue.
  I see the assistant Republican leader, the whip. I have heard a 
number of people say, and I will just propound this question and then I 
will yield the floor, if I may, to the Senator from Arizona. But I have 
heard them say: Why are Republicans keeping everybody in here this 
week? We want to go home and see our families.
  We all want to see our families. But there is a reason this bill was 
suddenly presented to us in the middle of the greatest snowstorm in the 
history of Washington in the month of December, and we were asked to 
start voting on it in the middle of the night on the same day, and to 
finish the work by Christmas. If I am not mistaken, and this is my 
question to the distinguished assistant Republican leader who has been 
here a number of years, who is in the leadership and whose job is to 
help manage the floor: Is it not entirely the prerogative of the 
majority leader of the Senate to schedule what comes up on the floor? 
Is that not his job? Isn't it true that if Senator Reid wanted to say 
let's take this bill down, let's go home, let's let the people hear 
about it, let's come back and vote on it after Christmas, after New 
Year, after Valentine's Day, could he not do that and isn't that 
peculiarly his power and not our power?
  Mr. KYL. Mr. President, I would say to our colleague, as a general 
rule that is correct. The majority leader has two great powers that no 
one else in the Senate has. One is the right of first recognition by 
the Presiding Officer and the other is the power to set the schedule. 
That power is limited by Senate rules, and it can be altered by 
unanimous consent. I can go on and explain a little bit to folks who 
are wondering why we would be in this predicament of voting on 
Christmas Eve based upon the majority leader's decision. If I can just 
proceed, I will do that.
  All of these rather odd times for debates, 1 o'clock in the morning, 
7:20 a.m. in the morning, and so on, are as a result of the majority 
leader's decision to make sure that this bill is completed by 
Christmas. That is the precipitating cause for everything else that 
follows because once he says the bill has to be completed by Christmas, 
then he has to, in effect, count backwards on how long it takes to do 
the various things the Senate rules say we have to do.
  If there are three cloture motions filed--which is what the majority 
leader did; he filed three cloture motions simultaneously--under Senate 
rules certain timeframes then attach.
  You have to take the vote with 1 day intervening between the filing 
of the cloture motion and the vote. If cloture is invoked, then 30 
hours for debate is permitted after which there can be additional 
action by the Senate. So when the majority leader takes all that into 
account, he finds that he has to vote at 1 a.m. in the morning, 7:20 
a.m, and so on.
  He could change that, of course. He could change that by saying we do 
not actually have to have the whole thing completed by Christmas. That 
is strictly an arbitrary date he set.
  There have been some who said: Why don't we have a unanimous consent 
request to not put us through all of this and try to complete the 
debate a couple of days earlier?
  Republicans have said: Now wait a minute. You are telling us on the 
one hand that the majority leader is saying we have to have this 
completed by Christmas, but since that is kind of tough on all of us, 
now you are saying let's move that up a couple of days.
  Republicans are saying: We have had barely enough time to consider 
this bill as it is. We are not going to agree to move it up any more 
than that. We don't like voting on Christmas Eve any more than you do, 
but the answer to it is not making the time even shorter but, rather, 
taking our time and doing it right. As the Senator from Maine has 
pointed out, let's go home for the Christmas recess, stop and listen to 
what our constituents are telling us they would like to have us do, and 
then come back and complete it. That could all be done by unanimous 
consent. My colleague is correct that once the majority leader made the 
decision that this has to be done by Christmas, then the time is pretty 
well set by the Senate rules, absent a unanimous consent by the body 
that would either extend the time or shorten that amount of time.
  I would like to make another point, off that subject if I could, but 
if my colleague has another question in that regard I would be happy to 
try to respond it.
  Mr. ALEXANDER. No, I thank the Senator. I yield the floor.
  Mr. KYL. I talked to the Senator from Wyoming. Of course, Arizona is 
a State that has a lot of Medicare patients. Our State is hurt as much 
as any by the cuts to Medicare and particularly the Medicare Advantage 
cuts. We do not have the benefit that was extended to residents of 
other States, primarily the State of Florida, by a special provision 
that was inserted into the bill. As a result, our constituents are 
going to suffer more than those of some other States.
  But the more we read this bill--and one of the reasons Republicans 
have not been willing to truncate this debate is that the more we read 
it the more we find in it that is troublesome. We found yesterday that 
the Congressional Budget Office--actually the Congressional Budget 
Office brought to our attention the fact that they had made a little 
mistake. I think it was a quarter of 1 percent in one of their 
calculations. That quarter of 1 percent amounted to $600 billion. So a 
small error by the Congressional Budget Office can make a huge 
difference to the people of America. That is $600 billion.
  We also saw there were special provisions in the bill for residents 
of one particular State, and that has gotten quite a bit of attention 
lately. There has also been a dental/vision clinic in a State that has 
benefited. I am still not sure we have figured out exactly what that 
State is, but I understand one of the Senators from Connecticut has 
taken credit for it. I don't know if that is true. It is hearsay. If 
that is incorrect, I can be corrected. But the more we see about it, 
the more we realize that support for it was garnered, not on the merits 
but on the basis of special favors done to certain Members.
  My staff has indicated there is yet another one of these in the bill, 
and it has to do with so-called specialty hospitals or, as they are 
referred to in the legislation, physician self-referral hospitals, that 
have physician ownership.
  Just a little bit of background on this. The Hospital Association 
that is primarily representative of the community hospitals has been 
pleading for

[[Page 32937]]

a long time that they are not adequately reimbursed, and we need to try 
to help them. I have been an advocate for that. I have tried to help 
them, for example, for reimbursement in the care provided to illegal 
immigrants, and we were successful in that.
  But one area I departed from that is when they concluded the best way 
to help themselves was to hurt their competition. At that point I said 
no. Their competition is the physician-owned, self-referral hospitals. 
These are generally specialty hospitals in a community that provide 
very good care. While they do in one sense provide competition to the 
community hospitals, they are all in the same boat in terms of the kind 
of reimbursement that Congress provides. What I have said is you should 
not solve your problem by hurting your competition but having Congress 
solve the problems that affect you both. I have been willing to try to 
help on that.
  In this legislation what they have done, they struck a deal with the 
Hospital Association to stop the competitors, the physician self-
referred hospitals, from building any more hospitals. You have to be 
under construction by a certain date under the bill--it is February 10, 
2010. You have to have a provider agreement in operation--that is the 
technical term--or else you cannot go any further with your new 
physician self-referred hospital. That is going to hurt a lot of 
communities. It turns out that some of the communities hurt were in a 
particular State, the State of Nebraska.
  Again, I have an affinity for Nebraska because I was born there, and 
I know a lot of people there. The Senator from Nebraska, Mr. Johanns, a 
little bit earlier today said he didn't think the special deals that 
were created for the State of Nebraska were appreciated by Nebraskans 
who stand more on principle and have the view that if something is bad 
for Nebraskans and it is bad for the folks in other States, therefore 
it ought to be solved for all of the States, not just for the State of 
Nebraska.
  It turns out that is the case with this particular provision on page 
332 of the Reid so-called managers' amendment, which would extend the 
date on which a hospital may have physician investment and a provider 
agreement in place for the purpose of being grandfathered. That date 
was extended until August 1, 2010.
  It turns out that helps, at least according to staff, at least three 
hospitals in the State of Nebraska--one in Omaha, one in Kearney, and 
one in Bellevue. In fact, I will just quote briefly from an article 
that Robert Pear of the New York Times did on this.

       The Senate health bill, would impose tough restrictions 
     like the one passed by the House last month, would impose 
     tough new restrictions on referrals of Medicare patients by 
     doctors to hospitals in which the doctors have financial 
     interests. The package assembled by Mr. Reid would provide 
     exemptions to a small number of such hospitals, including one 
     in Nebraska.

  He goes on to describe this and then quotes Molly Sandvig, executive 
director of Physician Hospitals of America, which represents doctor-
owned hospitals, who said the change would benefit Bellevue Medical 
Center, scheduled to open next year in Bellevue, NE.

       Under the proposal Ms. Sandvig said, ``doctor-owners can 
     continue to refer Medicare patients to the hospital'' in 
     eastern Nebraska.
       ``Senator Nelson has always been a friend to our 
     industry,'' she said. ``But doctor-owned hospitals in other 
     states were not so fortunate. They would not meet the August 
     1 deadline.''

  I would like to help all the physician-owned hospitals. I agree that 
all of them should have the same kind of support that was gained by the 
Senator from Nebraska for three specific hospitals in Nebraska. I 
understand, by the way, that three or four hospitals in Arizona would 
also benefit from that. I think that is a great thing.
  But instead of just benefiting the hospitals in a few States by 
moving the date back to where you catch the ones in the State of 
Nebraska, we ought to eliminate this requirement altogether because 
what you are going to do is prevent more competition from very high-
quality hospitals in communities that can provide a real service to 
constituents in all of our States, not just one State.
  It is just one more example, I say to my friend from Tennessee, that 
the more we read the bill and learn what is in it, the more we find 
that the 60 votes for it were obtained less by persuasion and on the 
merits of the bill than by special provisions that were inserted to 
assist folks in particular States.
  As I said, I think if something is good for one State, it ought to be 
good for all States. If it is not good for one State, it ought not be a 
requirement on the other States as well.
  Mr. BARRASSO. Mr. President, what you are hearing is what we are 
noticing as Republicans take a look at the bill. I saw the majority 
whip come onto the Senate floor a few minutes ago. Yesterday he was on 
the floor and said the Republicans have not offered amendments to this 
bill, so I brought four amendments yesterday. The chairman of the 
Finance Committee objected.
  One had to do with letting people on Medicare keep their own doctors 
or choose who they want to go to see for a doctor. The purpose of this 
what was called ``Medicare Patient Freedom to Contract'' is it ``allows 
Medicare patients the right to privately contract for medical services 
with the physician of their choice.''
  I ask my friend from Tennessee, who has just spoken about Medicare, 
wouldn't he think that patients who have been promised that they can 
keep the health care they want should be able, or at least this Senate 
ought to be able to debate an amendment about allowing Medicare 
patients the right to privately contract for medical services with the 
physician of their choice? Wouldn't that seem fair?
  Mr. ALEXANDER. Mr. President, I agree with the Senator from Wyoming. 
I think it is important for the American people to know, the 400-page 
amendment that was added to the underlying bill over the weekend is 
being presented to us in way that will not allow the bill to be 
amended. So something that affects one-sixth of the economy, which we 
have had a day and a half to read, which is part of an overall bill 
that will raise taxes, cut Medicare, and send big bills to States could 
be improved with amendments but cannot be amended under the current 
procedure.
  Mr. BARRASSO. Another amendment--I see my colleague from South Dakota 
is here--is an amendment I offered on the floor of the Senate yesterday 
to protect individuals from skyrocketing insurance premiums. You may 
recall the President of the United States said premiums--families in 
Wyoming and other States, families across the country--health insurance 
premiums would go down $2,500 per family. Yet what I read and studied, 
and as I look at this, it says to me it looks like premiums will go up 
instead of going down. Instead of going down $2,500, they will go up 
$2,100. I think for 90 percent of the families in this country, their 
insurance premiums will either stay the same or go up more because the 
bill is passed than if we did nothing.
  I ask my friend from South Dakota--I know he has been bringing forth 
information; I know he put a chart together on it--would there not be 
some value in allowing the Senate to discuss an amendment because this 
amendment basically said let the State insurance commissioners--because 
every State has an insurance commissioner--let the State insurance 
commissioner take a look at what happens to insurance premiums in their 
State. If the insurance commissioner finds that the premiums have gone 
up faster than the Consumer Price Index, then in that State where those 
premiums have gone up faster than the Consumer Price Index, all of 
these laws and regulations and rules would no longer apply. The 
mandates, the rating rules, the benefit mandate, all of those included 
in the Reid bill would not apply.
  Wouldn't that make sense, I ask my colleague from South Dakota? What 
is the Senator's understanding of this and should not we be allowed to 
at least discuss and debate that as a Senate when we have been promised 
as citizens of this country that premiums would go down?

[[Page 32938]]

  (Mrs. Hagan assumed the Chair.)
  Mr. THUNE. Madam President, the Senator from Wyoming is correct. Of 
course, we would like to offer amendments. I know the Senator from 
Wyoming has deep experience in this field, being a practicing 
physician, someone who brings great knowledge and background to the 
debate and obviously has great insight about how this 2,100-page bill 
could be improved upon. What we have here is the 2,100 pages that we 
started with, and this represents one-sixth of our entire economy. We 
are talking about reordering one-sixth of the entire economy. Saturday 
we received an amendment, a 400-page amendment which nobody up until 
Saturday had seen. In fact, many of the Democrats hadn't seen it 
either, including members of the Democratic leadership. There was a 
discussion on the floor last week between Senator McCain and Senator 
Durbin in which Senator McCain said: They are writing this amendment 
behind closed doors. We don't have any idea what is in it. The Senator 
from Illinois, the No. 2 person in the Democratic leadership, said: I 
am in the dark just like you are. You had a handful of people who were 
adding 400 pages of content to the 2,100 pages we already have.
  In addition, there is another amendment that adds another 300. We are 
talking about 2,700 pages that will reorder and restructure literally 
one-sixth of the entire American economy. Right now what we are being 
told is that we are not going to be allowed to offer amendments to that 
humongous piece of legislation. When you get this much legislation 
coming at you and receiving this on Saturday, not having the 
opportunity to read it for the first time, is why we have been saying 
we need to push this back and not try to jam it through before the 
Christmas holiday. You find all kinds of things in these bills. 
Sometimes people take credit for those being there. Sometimes they 
don't. We have had a debate about some of the provisions that benefit 
specifically Nebraska. You have this Medicaid provision that requires 
the taxpayers of the other 49 States to subsidize and pay the Medicaid 
matching share for the State of Nebraska which will cost millions and 
millions of dollars. The Senator from Arizona mentioned this late add, 
a $100 million item for construction of a university hospital which, 
again, is being reported as being inserted by the Senator from 
Connecticut. You have all these sorts of deals that get made to try and 
get that elusive sixtieth vote that are now coming to light. The 
American people have a right to know it. Frankly, Members of the Senate 
who have to vote on this have a right to know what is in these volumes 
of pages, 2,700 pages, that will spend $2.5 trillion. The original 
2,100-page bill spent $1.2 billion per page, $6.8 million per word. It 
creates 70 new government programs. This is a massive overhaul of 
health care delivery.
  What it ought to be about is driving down the cost of health care for 
people. In fact, we have heard a lot of discussion from the other side 
about how this drives down the cost of health care. This bends the cost 
curve down. They can say that, but the experts we rely on, the referees 
or the umpires, say otherwise. In fact, what the CBO has said is that 
the cost curve would be bent up by this bill. The blue line on this 
chart represents the increasing health care costs year over year if we 
do nothing. The blue line represents what we would be looking at if we 
continue on the current course which everybody here acknowledges is 
unacceptable. We all want to see the cost curve go down and see overall 
health care costs go down. But the ironic thing is, according to the 
CBO, the red line represents what happens if the bill proposed by the 
Democratic majority actually becomes law. The cost curve is bent up. We 
will actually spend more on health care than we are spending today, 
even the year-by-year twice the rate of inflation increases in health 
care premiums today.
  The Senator from Wyoming is absolutely right to be offering 
amendments to address the issue of premiums. This bill does not do 
anything to reduce premiums for most Americans. About 10 percent of 
Americans, because of the subsidies in the bill, would get their 
premium costs reduced, but 90 percent--we are told by the CBO--would 
see their premiums stay the same or go up. When I say stay the same, it 
means go up at the current rate of twice the rate of inflation. Worst-
case scenario, if you are buying your insurance in the individual 
marketplace, you will see your insurance premiums go up above and 
beyond this by 10 to 13 percent. Health care costs for 90 percent of 
Americans, the best they can hope for, is the status quo which is year-
over-year increases that are twice the rate of inflation. If you are 
one of the unlucky who buys their insurance in the individual 
marketplace, your premiums go up by another 10 to 13 percent. This 
ought to be about driving down health care costs and getting premiums 
under control.
  The overall cost of health care in this country represents about one-
sixth of our entire economy. If this bill passes, according to the 
Congressional Budget Office, according to the Actuary of CMS, health 
care spending will no longer be one-sixth of the economy; it will be 
more than one-fifth. Because if this bill passes, health care spending 
will go up to about 21 percent of our gross domestic product.
  Tell me, what does this bill do then to get costs under control? If 
we are driving up the cost of health care for individuals in the form 
of higher premiums, if we are driving up the overall cost of health 
care as a percentage of our economy, why would we be jamming this thing 
through before the Christmas holiday, these 2,700 pages, spending $2.5 
trillion of taxpayer money, raising taxes on small businesses, which 
obviously have weighed in on this, and the National Federation of 
Independent Business, which represents a lot of small businesses around 
the country, has said, if enacted, this bill would cost us 1.6 million 
jobs because of all the new taxes it imposes--you are raising taxes, 
when fully implemented, by about $1 trillion, cutting Medicare by about 
$1 trillion. After all that, what do you have? You have the same or 
worse insurance premiums for 90 percent of Americans. I argue that is a 
bad deal for the American people.
  Coming back to the special deals, this is not the way to legislate. 
To carve out deals, to go and try and find or buy or however you want 
to characterize it that sixtieth vote is essentially what we are 
talking about. These are special goodies packed into this bill 
essentially because the majority decided that rather than trying to 
include Republicans and pass it with Republican votes, they had to pass 
it with all Democrats which meant that every one of the Democrats had 
tremendous leverage. Clearly, they decided to use it. There are lots of 
carve-outs, lots of special deals in this that cost the American 
taxpayers hundreds of millions of dollars in additional spending simply 
because they wanted to get this done by an artificial deadline and 
wanted to do it with all Democratic votes.
  I say to my colleagues, this process itself, when the American people 
find out about particularly this latest deal, smells. I don't think 
they are going to like it. I don't think they are going to like the end 
product when they find out it will raise insurance premiums.
  Mr. BARRASSO. I try to stay in close touch with the people of 
Wyoming. I go home every weekend. We have not been able to do that the 
last couple of weekends so I have had telephone townhall meetings. I 
know the Senator from Tennessee has done the same. There is a way 
people can push a button to indicate whether they are in favor or 
against. Ninety-three percent of the people of Wyoming are opposed to 
the bill the Democrats are trying to jam through in the middle of the 
night. I know the Senator from Tennessee has recently had telephone 
townhall meetings with his constituents because he was not able to be 
home personally with them. Maybe the Senator wants to share with us 
some of the experiences he has had and some of the messages he has 
heard from the fine folks of Tennessee.
  Mr. ALEXANDER. Madam President, the telephone townhalls are 
interesting. This is the 21st consecutive day

[[Page 32939]]

and the third weekend we have been debating this bill. One would think 
we could probably do a better job of it, if we were going back home 
every weekend to hear what people thought about what we were doing. But 
maybe the strategy has been to keep us here talking to each other, 
bring the bill up in a snowstorm, pass it in the middle of the night 
and go home for Christmas, and the people won't find out what we are 
doing until it is too late. One way to find out is tele-townhalls. I 
was skeptical before I did one but it is a pretty interesting way to 
stay in touch with people from Tennessee. You get on the telephone and 
an automated system calls thousands of people and says: The Senator 
from Wyoming or Illinois or North Carolina or Tennessee wants to talk 
with you about health care. People can either stay on the phone when 
they get the call or they can hang up. What normally happens is a 
person stays on the call, this time a surprisingly large number of 
people stayed on the call, because of their strong interest in this 
issue.
  The other night I did the phone call between 7:30 and 8:30. I called 
to about 18 west Tennessee counties, including Shelby, which is 
Memphis, and as reported to me by the service, about 30,000 people were 
on the telephone sometime during that hour, with a maximum number of 
3,016 on the call at any one time. Someone might pick up the phone and 
say: Senator Barrasso is on the phone. They might tune in for 15 or 20 
minutes and then hang up. Maybe they have to cook dinner or the ball 
game comes on. Maybe they get tired of talking to you, but they are on 
for 15 or 20 minutes. During that time, I was able to take a number of 
questions. After it was over, 563 messages from constituents were sent 
to my Web site.
  It was interesting to me. People who know my history, know that to be 
elected Governor 30 years ago, I walked across the State of Tennessee. 
Instead of going to a Republican meeting or a rotary club, I would 
visit with random people during my walk. It took me 6 months and I 
would see 1,000 people a day. These random phone calls kind of reminded 
me of that. It was as if the people were randomly selected. They were 
not on any Republican list or Democratic list or list of doctors or 
patients. They were just in the phonebook. They talked and acted like 
they were normal citizens who I had interrupted after dinner, probably 
because it was 6:30 to 7:30 in that part of Tennessee. I was able to 
ask those citizens three questions. I am not about to say this is a 
Gallup poll of Tennessee, because I know that surveys like that have to 
be done in a scientific way, but after being here for 21 straight days, 
not able to go home because we have been debating this bill, these 
opinions are straws in the wind.
  The first question was: Do you believe the Senate should rush to pass 
this health care bill before Christmas? In this case, 943 people, 83 
percent, said no, and 108 said yes; that is 9 percent.
  Second question: Do you support the health care bill moving through 
the Senate? On this one, 1,496 said no, or 75 percent. 352 said I don't 
know, which is 18 percent, and 154 said yes, that is 8 percent.
  No. 3: Do you agree that Congress doesn't do comprehensive 
legislation well and ought to go step by step to bring health care 
costs under control? On this question, 1,285 said yes, that is 80 
percent, 14 percent said I don't know and 7 percent disagreed.
  I have often heard our friends on the other side say: Where is the 
Republican bill? My response has been, day after day, if you are 
looking forward to seeing the Republican leader role a wheelbarrow in 
here with a 2,700-page Republican comprehensive bill, you will be 
waiting forever. We have a different approach. Our approach is to set a 
clear goal--reducing cost. The bill we are voting on increases costs. 
Our goal is to find five or six steps to go in the direction to 
reducing costs.
  Without going into detail, although the Senators from South Dakota or 
Wyoming may want to, we focus on five or six steps that would clearly 
reduce health care costs. By that, I mean your premium, the cost of 
your government. And once we do those five or six steps, we could go 
on. We could do that without taxes, without mandates, without running 
up the debt, without a big bill with lots of surprises. Just to take 
one example--and then I will yield to my friends from Wyoming and South 
Dakota--one of those examples is the small business health care plan. 
The current bill, the Democratic bill, has in it a credit for small 
businesses, but we would argue that by the time small business men and 
women get through paying the mandates and the taxes the bill also 
imposes, it is not going to be much help to them.
  What we have is a bill that would allow small businesses to pool 
their resources. In other words, if you are a small business man or 
woman and you have 60 employees and 2 get cancer, suddenly the costs of 
those 2 employees prohibit you from providing insurance to the other 
employees. But if you could pool your resources with small businesses 
all around the country, then the pool would be large enough that you 
could offer insurance.
  That proposal has been made by Senator Enzi. It has been through the 
HELP Committee. The Congressional Budget Office said it did not add to 
the deficit. In fact, it reduces the deficit, and it would permit 
750,000 more employees of small businesses to be insured and their 
premiums would be lower than they otherwise would be. That is a single 
step to moving toward reducing health care costs, but if we took that 
step and the other steps we have proposed, that would be a good way to 
start. We could do that together, and we would not have this partisan 
bill with so many questions and so many concerns.
  So I wonder if my friends from South Dakota and Wyoming--I know they 
have thought a good deal about this step-by-step approach toward 
actually solving the real problem of health care costs.
  Mr. THUNE. If the Senator will yield on that suggestion of small 
business health plans, doesn't that enjoy wide support among small 
businesses in this country?
  Mr. ALEXANDER. It clearly does. It enjoys widespread support 
everywhere, except the Senate. When Senator Enzi brought it up, it was 
rejected by our friends on the other side.
  Mr. THUNE. If I might continue, the one thing that strikes me about 
this proposal that, as I said before, now is, in totality, 2,700 pages, 
is that it does not enjoy any support from any small business 
organization that I know of. Maybe there are some out there I cannot 
speak to. But I do know the organizations that represent small 
businesses that we are all well acquainted with--National Federation of 
Independent Business, the Chamber of Commerce, the National Association 
of Manufacturers, the National Association of Wholesalers and 
Distributors, builders and contractors, electric contractors, franchise 
associations--I can go right down the list--all say this does nothing 
to lower their costs. In fact, it increases the cost of doing business, 
increases the cost of doing health care.
  What they have argued repeatedly is one of the suggestions the 
Senator from Tennessee mentioned, that small business health plans 
would drive their health care costs down, which is why they have been 
such strong advocates for this over the years.
  I guess the other question I would ask of my colleague from Tennessee 
is, would an approach, a suggestion like small business health plans 
require tax increases that would hit small businesses?
  Incidentally, the latest version with the managers' amendment, which 
we just received Saturday, increases the tax increases in the bill that 
were previously $493 billion and are now $518 billion. As the Senator 
mentioned, with the tax credit businesses get, they up that a little 
bit but not enough to help most small businesses in light of the $518 
billion in tax increases in the first 10 years, and when it is fully 
implemented it will be about $1 trillion. But the payroll tax that is 
going to hit a lot of small businesses was increased dramatically in 
the managers' amendment. The individual mandate was almost doubled in 
the managers' amendment. So the taxes in the bill go up with this 
proposal.

[[Page 32940]]

  I guess my question is, with all these tax increases that are going 
to have a crushing impact on small businesses, does a suggestion such 
as the one made by the Senator from Tennessee for small business health 
plans require tax increases or Medicare cuts, which is what is going to 
be necessary to finance this 2,700-page behemoth?
  Mr. ALEXANDER. I thank the Senator from South Dakota. The answer is 
no. The difficulty with a big, comprehensive plan is it sounds good but 
has lots of unintended consequences. If our real concern right now is 
reducing costs in health care, then the idea of a small business health 
care plan that has no new taxes and no new mandates but creates 
opportunities for small businesses to pool their resources and offer 
more insurance at a lower cost to their employees would seem a logical 
place to start.
  Mr. THUNE. I appreciate the Senator for his work on that issue. It is 
a view I share, a proposal I have been a big advocate of going back to 
my days in the House of Representatives and one which, as the Senator 
from Tennessee noted, has tremendous support among small businesses 
across the country. About the only place it does not have majority 
support is here in the U.S. Congress because maybe it makes too much 
sense.
  But it seems to me there are suggestions and solutions out there 
which do not require $\1/2\ trillion of tax increases on small 
businesses, which every small business organization has come out and 
said: It is going to drive up our cost of doing business, and at the 
end of the day, it is going to raise our health care costs--and does 
not require these steep Medicare cuts that the Senator from Wyoming has 
alluded to over and over again and the impacts those will have on the 
delivery of health care to seniors across this country but, rather, it 
would bend the cost curve down without tax increases and Medicare cuts.
  Another example of that, I would argue, would be allowing for 
interstate competition, allowing people to buy their insurance across 
State lines, which is a suggestion we have made over and over on our 
side of the aisle. According to the Congressional Budget Office, both 
small business health plans and buying insurance across State lines 
actually would reduce health care costs and would do it without raising 
taxes or cutting Medicare, which, to me, would make a lot of sense, 
especially when you have an economy in recession, 10-percent 
unemployment, a $1.5 trillion deficit last year and another $1.5 
trillion deficit this coming year, and when you are talking about a 
$2.5 trillion cost in the growth of government here in Washington, DC, 
to implement these 2,700 pages.
  Some suggestions along the lines of the one mentioned by the Senator 
from Tennessee and some of these others would make a lot of sense, and 
I think they would enjoy tremendous support among small businesses, 
which create the jobs in this country, as well as among the American 
public.
  So I thank the Senator from Tennessee for pointing out one of the 
many things Republicans are for and which we have tried to get in the 
debate.
  I know the Senator from Wyoming has advocated for many of these same 
types of initiatives and solutions. As he mentioned earlier, he was 
prepared to offer an amendment to address the issue of premiums, but it 
looks as if we are going to be prevented from doing that.
  Mr. BARRASSO. Our friends at the University of Minnesota said that if 
people were allowed to shop across State lines, shop around for 
insurance that is better for them and their family and their personal 
situation, we would have 12 million more Americans insured today than 
we have now, without a single page of legislation. That is all we need 
to do: allow people to shop across State lines. But when we talk about 
and look at this bill, which has mandates, there is going to be a 
mandate for people to buy insurance.
  One of the amendments I tried to offer yesterday that I thought made 
a lot of sense for young people was that for individuals under the age 
of 30 or for those making less than $30,000 a year, they would be 
exempted from the mandate, the individual mandate that they have to buy 
insurance.
  I was involved in a discussion on a college campus in a debate on 
this topic, and in talking to the students, they were astonished to 
learn--because they were not focused on this; they were focused on 
their studies and working--they were astonished that they are all going 
to have to buy, as a matter of law, if this passes, health insurance 
immediately, and if they do not, they are going to have to start paying 
a tax or a fine, depending on how you describe it.
  So in my amendment, I said, for those up to the age of 30 and making 
under $30,000 a year, let's exempt them from the mandate. That 
amendment was rejected.
  Then I said, well, if they are going to do this and force these 
people to buy insurance, and if they do not buy insurance, they have to 
pay these excessive fines or taxes--or however you want to define it--I 
said, how about that the penalties these people would have to pay, if 
they choose not to buy insurance--because it is going to be a lot 
cheaper to not buy insurance and to just pay the tax--what if that 
money could go into a personal account so that person can then use the 
money to then buy insurance? So it would be kind of like a savings 
account, so the money would be there for them to buy insurance. So 
individual mandate penalties would accrue not to the government but in 
a personal account, so they could purchase health insurance within a 3-
year period. The money would accumulate. That amendment was rejected as 
well.
  So we have lots of ideas, good ideas, to help people with affordable 
care, available care, and yet one after another they have been rejected 
in a step-by-step process to try to find ways to solve the health care 
crisis we know faces the country. All 100 Members of the Senate know we 
need to find ways to make health care more affordable and to work on 
high-quality care.
  It has been fascinating to see the dean of the Johns Hopkins Medical 
Center and the dean of Harvard and those who have looked at this bill 
closely say that the people who are supporting this are living in 
collective denial, that this bill is doomed to fail, that it will raise 
the cost of care, not lower the cost of care, and will do nothing to 
improve quality.
  Mr. THUNE. If the Senator from Wyoming would yield on that point, 
that is why I think day after day after day--and I have said--there is 
a pattern emerging here in the Senate where the majority comes down and 
establishes the need for health care reform, which we all acknowledge, 
and illustrates examples of those who have fallen through the cracks, 
which we all know examples exist--all of us have dealt with those in 
our individual States--and then proceeds to attack Republicans for not 
having their own ideas, which we have just mentioned there are lots of 
good Republican ideas which do not raise taxes, which do not cut 
Medicare, and actually do something to reduce premiums. But that seems 
to be the strategy employed and the pattern that emerges in the 
rhetoric day after day down here from the other side.
  The one thing I do not hear is them coming down here and talking 
about what this 2,700-page bill is going to do to reduce health care 
costs, because if we all submit to the experts on this--which, as I 
said earlier, the Congressional Budget Office is sort of the referee. 
They do not have a political agenda, or at least they are not supposed 
to. The Actuary at the Centers for Medicare and Medicaid Services does 
not have a political agenda, or at least they are not supposed to. They 
are sort of considered to be an umpire on this. The Joint Committee on 
Taxation, which looks at the distributional impacts of tax policy, is a 
referee and is not supposed to have a political agenda in all this. 
They all come to the same conclusions with regard to premium increases 
in this bill.
  So if the overall objective is to reduce the cost of health care, and 
if, in fact, your legislation, according to all the referees, all the 
umpires, all the experts, not only increases premiums for most 
Americans but increases the overall cost of health care, which is what

[[Page 32941]]

they all conclude, it is pretty hard to come down and defend this 
product. That is why I think day after day they try to create 
distractions and counterattacks as opposed to actually coming down and 
talking about the substance of the bill because the substance of the 
bill does not accomplish the stated objective, which is to reduce the 
overall cost of health care and get premiums under control for families 
and small businesses in this country.
  It is also hard, I would argue, because of the $518 billion of tax 
increases that are in here and the unified opposition of the entire 
small business community, which creates 70 percent of the jobs in this 
country, to talk about how this can be anything but detrimental to job 
creation. This is going to cost us jobs. I think every business 
organization has made that abundantly clear. And all the analysis of 
this legislation that has been done comes to the same conclusion.
  Mr. BARRASSO. When you take a look at what the Centers for Medicare 
and Medicaid Services has done, which is the group that oversees 
Medicare, they have said that 10 years from now, if this goes through, 
you are still going to have 24 million uninsured, you are going to have 
18 million more on Medicaid, the program the Senator from Tennessee 
appropriately referred to as having a bus ticket for a bus that is not 
going to come, because that is what has happened. Half the doctors in 
the country do not take care of patients on Medicaid because the 
reimbursement is so low that they cannot afford to continue to care for 
those people. Five million people will lose the insurance they get 
through work, and health care costs will go up. The cost curve will go 
up instead of going down. But the whole purpose of this was to help 
drive the cost down.
  Then, additionally, they said that 20 percent of providers--20 
percent of the providers--of health care in this country--and that 
includes physicians, nurse practitioners, medical clinics, hospitals--
20 percent of the providers in this country, under this plan, 10 years 
from now, will be unprofitable, unable to keep their doors open.
  So we have heard about sweetheart deals. We have heard about taxes 
going up. We have heard about Medicare cuts. And what we have seen is 
one promise after another made by the President that has been 
unfulfilled and actually reversed by the bill we see ahead of us.
  So I ask my friend from Tennessee, wouldn't he agree that in the next 
2 days, the best thing for the country would be to have this bill not 
pass the Senate and instead go back in a step-by-step way and regain 
the trust of the American people?
  Mr. ALEXANDER. I certainly do agree with that.
  I think most Americans, when presented with a problem, would not try 
to change it all at once but would say: Let's identify the goal which 
is reducing costs and go step by step.
  Madam President, I ask unanimous consent to have printed in the 
Record a column by David Brooks in the New York Times on December 18.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                [From the New York Times, Dec. 18, 2009]

                            The Hardest Call

       The first reason to support the Senate health care bill is 
     that it would provide insurance to 30 million more Americans.
       The second reason to support the bill is that its authors 
     took the deficit issue seriously. Compared with, say, the 
     prescription drug benefit from a few years ago, this bill is 
     a model of fiscal rectitude. It spends a lot of money to 
     cover the uninsured, but to help pay for it, it also includes 
     serious Medicare cuts and whopping tax increases--the tax on 
     high-cost insurance plans alone will raise $1.1 trillion in 
     the second decade.
       The bill is not really deficit-neutral. It's politically 
     inconceivable that Congress will really make all the spending 
     cuts that are there on paper. But the bill won't explode the 
     deficit, and that's an accomplishment.
       The third reason to support the bill is that the authors 
     have thrown in a million little ideas in an effort to reduce 
     health care inflation. The fact is, nobody knows how to 
     reduce cost growth within the current system. The authors of 
     this bill are willing to try anything. You might even call 
     this a Burkean approach. They are not fundamentally 
     disrupting the status quo, but they are experimenting with 
     dozens of gradual programs that might bend the cost curve.
       If you've ever heard about it, it's in there--improved 
     insurance exchanges, payment innovations, an independent 
     commission to cap Medicare payment rates, an innovation 
     center, comparative effectiveness research. There's at least 
     a pilot program for every promising idea.
       The fourth reason to support the bill is that if this 
     fails, it will take a long time to get back to health reform. 
     Clinton failed. Obama will have failed. No one will touch 
     this. Meanwhile, health costs will continue their inexorable 
     march upward, strangling the nation.
       The first reason to oppose this bill is that it does not 
     fundamentally reform health care. The current system is 
     rotten to the bone with opaque pricing and insane incentives. 
     Consumers are insulated from the costs of their decisions and 
     providers are punished for efficiency. Burkean gradualism is 
     fine if you've got a cold. But if you've got cancer, you want 
     surgery, not nasal spray.
       If this bill passes, you'll have 500 experts in Washington 
     trying to hold down costs and 300 million Americans with the 
     same old incentives to get more and more care. The 
     Congressional Budget Office and most of the experts I talk to 
     (including many who support the bill) do not believe it will 
     seriously bend the cost curve.
       The second reason to oppose this bill is that, according to 
     the chief actuary for Medicare, it will cause national health 
     care spending to increase faster. Health care spending is 
     already zooming past 17 percent of G.D.R. to 22 percent and 
     beyond. If these pressures mount even faster, health care 
     will squeeze out everything else, especially on the state 
     level. We'll shovel more money into insurance companies and 
     you can kiss goodbye programs like expanded preschool that 
     would have a bigger social impact.
       Third, if passed, the bill sets up a politically 
     unsustainable situation. Over its first several years, the 
     demand for health care will rise sharply. The supply will 
     not. Providers will have the same perverse incentives. As a 
     result, prices will skyrocket while efficiencies will not. 
     There will be a bipartisan rush to gut reform.
       This country has reduced health inflation in short bursts, 
     but it has not sustained cost control over the long term 
     because the deep flaws in the system produce horrific 
     political pressures that gut restraint.
       Fourth, you can't centrally regulate 17 percent of the U.S. 
     economy without a raft of unintended consequences.
       Fifth, it will slow innovation. Government regulators don't 
     do well with disruptive new technologies.
       Sixth, if this passes, we will never get back to cost 
     control. The basic political deal was, we get to have dessert 
     (expanding coverage) but we have to eat our spinach (cost 
     control), too. If we eat dessert now, we'll never come back 
     to the spinach.
       So what's my verdict? I have to confess, I flip-flop week 
     to week and day to day. It's a guess. Does this put us on a 
     path toward the real reform, or does it head us down a valley 
     in which real reform will be less likely?
       If I were a senator forced to vote today, I'd vote no. If 
     you pass a health care bill without systemic incentives 
     reform, you set up a political vortex in which the few good 
     parts of the bill will get stripped out and the expensive and 
     wasteful parts will be entrenched.
       Defenders say we can't do real reform because the politics 
     won't allow it. The truth is the reverse. Unless you get the 
     fundamental incentives right, the politics will be terrible 
     forever and ever.

  Mr. ALEXANDER. Most of us--we are pretty split up here: 60 there, 40 
here. They are for it, and we are against it, this bill anyway.
  The PRESIDING OFFICER. The minority time has expired.
  Mr. ALEXANDER. I thank the Presiding Officer and I yield the floor.
  The PRESIDING OFFICER. The Senator from California.
  Mrs. BOXER. Madam President, we heard our Republican friends say it 
is very hard to defend our bill. Maybe it is hard for them, but it is 
not hard for the American Medical Association, the AMA, which has 
endorsed our bill. It is not hard for the American Heart Association, 
which has endorsed our bill. It is not hard for the American Cancer 
Society Action Network, which has endorsed our bill. The American 
Hospital Association has endorsed our bill. Families USA, the Business 
Roundtable, the Small Business Majority--we hear colleagues say small 
business opposes our bill. The Small Business Majority Organization 
supports it. And how about the AARP, which represents our seniors, 
millions of seniors. Those are a few. They not only defend our bill, 
they support our bill.
  This is indeed an important moment in our Nation's history as we 
approach a final vote on major health care reform legislation. I think 
whenever you are trying to change something, you

[[Page 32942]]

have to take a look at how things are at the moment. So why is it we 
voted to change our current system? There are certain numbers that I 
think explain it. The first number is 14,000. We know that every single 
day 14,000 of our neighbors lose their health insurance through no 
fault of their own. They either lose their job, they can't afford to 
keep up the health insurance or they have a condition and the insurance 
company walks away from them or they are priced out of the market. 
Fourteen thousand a day. That is cruel, and we need to change it.
  Sixty-two percent of bankruptcies are linked to health care crises. 
We are the only nation in the world where people go broke because they 
get sick.
  If we do nothing, 45 percent of an average family's income will go 
for premiums in 2016. I ask everyone to think about it, paying 45 
percent of your income for premiums. It is not sustainable. What about 
food? What about clothing? What about shelter? Can't do it.
  We are 29th in the world in infant mortality. We come in behind Cuba. 
We come in behind Singapore. We come in behind South Korea. We are 29th 
in the world on infant mortality because people don't have good 
insurance or they don't have any insurance.
  Fifty-two percent of women--fifty-two percent of women--don't seek 
the health care they need. They either put it off or they never get it 
because they may not be insured or they are afraid of the copays. They 
are afraid of what it would cost. They may have limits on their 
policies. We need to change that.
  The United States spends twice as much on health care as most other 
industrialized nations. So what is the message here? We spend a huge 
amount. We are not doing very well in outcomes. By the way, I think we 
are 24th in life expectancy in the world--24th. We must do better.
  I wish to share with my colleagues some of the letters and e-mails 
that have been sent to me from Californians that personalize the 
statistics I spoke about.
  Mr. William Robinson wrote:

       I am about to be laid off from the job I have had for 19 
     years. My biggest fear is not being employed, but being able 
     to find and get affordable health care. I am 60 years old. I 
     have a preexisting condition that will for certain make it 
     impossible for me to buy health insurance.

  Mr. and Mrs. Gilbert De La Cruz wrote:

       We are at the point of losing our home because we have 
     spent our savings on medical and prescription drugs. I am 67, 
     retired, and my wife is 62. Because of the Medicare gap in 
     prescription drug coverage, we have had to pay $600 a month 
     on prescription drugs. It's a huge portion of our monthly 
     income. We will be selling our home shortly and perhaps 
     moving in with one of our children because there doesn't seem 
     to be any option.

  Well, I want to say to Mr. De La Cruz: Help is on the way. If we get 
the 60 votes we are forced to get--not 51, a majority, but 60 votes 
because of a Republican filibuster--if we get those 60 votes each time, 
there is hope for you because we are going to fix that entire problem.
  Mr. Ronald Kim says:

       I am in the construction industry and my work is very slow.

  He says he is in the design industry.

       I am in danger of becoming financially ill and I am looking 
     for ways to stay healthy, and one way may be to eliminate my 
     medical insurance. It is a significant part of my budget. 
     This may, heaven forbid, lead me to financial ruin if I get 
     injured or sick. This is my situation.

  I want to say to Mr. Kim: Help is on the way.
  Ms. Madeleine Foot wrote--these are all Californians, my 
constituents:

       I recently turned 25 and I lost my health coverage under my 
     parents. I attempted to get coverage under a Blue Cross plan 
     created for young people my age, but because I had taken 
     medications, I was denied. I applied again for another plan, 
     was offered a plan with a $3,000 deductible, and it was $300 
     a month on top of that. As a young person working in a 
     restaurant, repaying student loans and trying to make it on 
     my own, this is a huge financial burden. I cannot afford an 
     insurance that charges me so much and won't be any benefit 
     for me until I have shelled out a huge portion of my income.

  To Madeleine Foot I say: Help is on the way, if we can break the 
Republican filibuster.
  Mr. John Higdon wrote:

       As a self-employed person, I had a pacemaker implanted. The 
     cost was borne entirely by me at prices much higher than any 
     insurance company would have had to pay. That was a wakeup 
     call to get health insurance. I am told by every health 
     insurance company I have contacted that no one will offer me 
     health insurance at any price with a ``preexisting heart 
     condition.''

  I wish to say to Mr. Higdon: Help is on the way.
  Dr. Robert Meagher, a pediatrician with Kaiser Permanente for over 30 
years, do you know what he wrote and told me? That he has to fake--he 
is pressured to fake a diagnosis because when a parent comes in with a 
young child with asthma, they beg him not to write down asthma but 
write down bronchitis, because if he writes down asthma, that child 
will have a preexisting condition and when she turns 21 she won't be 
able to get insurance. Imagine, in America, a physician being pressured 
to lie on a form because of a health care system that is so cruel.
  So, Dr. Meagher, we are going to change things here if we can break 
this filibuster.
  Mr. Douglas Ingoldsby wrote:

       I own a small business. I employ 11 people. I have been in 
     business in California since 1972.

  He says:

       I used to provide health care for all my employees and all 
     the members of their families, and if I want to remain 
     profitable enough to stay in business now, I can't do it 
     anymore.

  He can only cover the employees, not their families. He feels 
terrible about it, and he says he may have to cut off his employees if 
prices keep going up.
  I want to say to this fine small business owner: Douglas, help is on 
the way.
  Mrs. Linda Schumacher wrote--and this is the one I will close with in 
this series of stories:

       I am a Republican.

  Let me repeat what she writes:

       I am a Republican, and my husband and I are small business 
     owners. The Senators and Congressmen of both parties who are 
     against President Obama's plan have their own insurance, and 
     it is my understanding that it does not cost what we pay. 
     They do not understand what a huge expense this is. Please 
     listen to the middle class who are in our position or who no 
     longer have insurance. It keeps me up at night worrying. This 
     time the Republicans have it wrong, and they need to know. 
     Please push the health plan. The insurance companies only 
     care about the bottom line, not people.

  I wish to say to Mrs. Schumacher: Thank you for putting aside party 
politics, because this isn't about Republicans and it isn't about 
Democrats and it isn't about Independents. It is about all of us 
together.
  What happens now? We are hearing the polls, and the polls show 
Americans don't want us to act. I understand why. There has been so 
much misinformation. Senator Durbin, our assistant majority leader, and 
I were talking about the misinformation that is on this floor from the 
other side day in and day out, and I believe much of it, if I might 
say, is purposeful. If you listened to my Republican colleagues over 
the past few days and weeks, they have trashed this bill and they have 
trashed the process. Over the weekend the Republican leader said health 
reform is a legislative train wreck of historic proportions. That is a 
direct quote.
  Earlier this month Senator Coburn used more inflammatory language 
when he said to seniors--I am quoting Senator Coburn: I have a message 
for you. You are going to die soon.
  If you want to know what fearmongering is, that is the best example I 
can give you.
  I decided to go back and look at the past Congressional Records. I 
thought: Have Republicans spoken like this over the years every time we 
have tried to do some health care, every time we have tried to make 
life better for people, such as Social Security? I will let you be the 
judge.
  In 1935, on the floor of the House of Representatives during the 
debate on Social Security, Republican Congressman Jenkins of Ohio 
said--a Social Security bill, remember, which hadn't passed:

       This is compulsion of the rankest kind. Do not be misled by 
     the title. The title says ``Old-Age Benefits.'' Shame on you 
     for putting such a misleading and unfair title on

[[Page 32943]]

     such a nefarious bill. Old age benefits? Think of it. Oh, 
     what a travesty! . . . Mr. Chairman, what is the hurry? 
     Nobody is going to get a dime out of this until 1942 . . . 
     what is the hurry about crowding an unconstitutional 
     proposition like this through the House today?

  If you listen to some of my colleagues, you will hear the same thing. 
What is the rush? As a matter of fact, they had four or five amendments 
to send it back to committee. What is the rush?
  The rush is that 14,000 people are losing their health care every 
day. The rush is that 62 percent of bankruptcies are linked to a health 
care crisis, and in 2016 our people will be paying almost half of their 
income for premiums. Yes. We have to do this, and we started it 7 
months ago, and 100 years ago Teddy Roosevelt, a Republican President, 
put it in his platform. What is the rush? What is the rush?
  I wish to tell my colleagues about another Republican Congressman, J. 
William Ditter of Pennsylvania. This is what he said during the debate 
on Social Security:

       . . . security for the individual, whether worker or aged, 
     will be a mockery and a sham.

  This is what he said about Social Security.

       And it will allot to our people the role of puppets in a 
     socialistic State.

  That is what he said back then. I tell you, if you ask Republicans 
who are getting Social Security, Democrats who are getting Social 
Security, Independents who are getting Social Security, they will all 
tell you the same thing: Keep your hands off it. It works. It is good. 
It is fair. It is insurance.
  It is what we did way back then.
  In 1965, when Medicare passed, health care for those 65 and up, 
Republican Senator Carl Curtis said:

       It is socialism. It moves the country in a direction which 
     is not good for anyone.

  Years later, we know Newt Gingrich when he was Speaker of the House 
said he wanted to see Medicare ``wither on the vine,'' his words.
  In 1995, while seeking the Republican nomination for President, 
Senator Bob Dole said:

       I was there in 1965 fighting the fight, voting against 
     Medicare, because we knew it wouldn't work in 1965.

  So when you hear our Republican friends say, Oh, my goodness, they 
are making a lot of savings in Medicare; this is bad for the seniors, 
please, please, which party has stood for protecting our seniors? It is 
not a matter of being partisan; it is just the fact.
  The echoes of the past fill this Chamber.
  I am convinced now in 2009 that hope and reason and determination and 
good policy will triumph over fear and obstruction and the status quo.
  Let's look at the immediate and near-term changes for the better that 
people are going to have, because our colleagues say: Oh, we are 
raising revenues but there are no benefits right away.
  Let's talk about what the benefits are. There will be a $5 billion 
high-risk pool immediately for people with preexisting conditions who 
cannot find insurance. There will be reinsurance for retirees, so if 
you are retired and you are getting your health care benefit and 
something happens to your company, there will be reinsurance so you can 
still get your benefits. We close that doughnut hole for the Medicare 
recipients who fall into it and suddenly they cannot afford their 
prescription drugs. There will be billions of tax credits--billions--up 
to 50 percent tax credits for small businesses. That is why we have the 
support of so many small businesses. For new policies, no 
discrimination against children with preexisting conditions, and 
children can stay on their family's policy until they are 26 years of 
age.
  What else are the immediate and near-term changes for the better? For 
new policies, no lifetime limits, no more rescissions. They cannot walk 
away from you when you get sick. They are required to cover essential 
preventive health benefits such as mammograms. It prohibits 
discrimination by employers based on salary of their employees. An 
employer cannot say: If you earn over $250,000, you get these great 
benefits, but if you earn under $50,000, you get a worse array.
  By 2011, standards for insurance overhead costs go into place. If 
your insurance company spends too much on overhead and too much on 
executive pay, let me tell you what happens. They have to rebate to 
you, the policyholder. We also see increased funding for community 
health care centers. This is going to make a huge difference. There 
will be a national Web site to shop for affordable insurance. There 
will be a long-term care program that is voluntary into which you can 
buy. Insurance companies with unreasonable premium increases can be 
barred from the exchanges that will be set up in 2014. So they will be 
making sure they do not increase your premiums beyond a reasonable 
amount.
  This bill will benefit the insured in one way--I do not think people 
understand this--by 2014; 62 percent of families will no longer face 
unsustainable premium costs. If you are a family of four and make less 
than $88,000 a year, you will never have to pay more than 9.8 percent 
of your income on health insurance premiums. This is an amazing thing 
most people do not focus on. I just explained that the nonpartisan 
studies show--and this is important--that they will be paying, the 
average family, 45 percent of their income for health care. In 2014, 
people in this country will not have to pay more than 9.8 percent of 
their income on health insurance; otherwise, they will get tax credits. 
That is very important.
  This bill is going to benefit our seniors. That is why it is endorsed 
by the AARP. We eliminate the prescription drug coverage gap. That is 
the doughnut hole. We extend the life of the Medicare trust fund by 9 
years. We reduce waste and fraud in Medicare. We provide for free 
yearly wellness visits for seniors. This bill saves Medicare. This bill 
makes our seniors stronger. They will have more benefits, and they can 
never lose their guaranteed benefits.
  Small businesses will be able to reduce their costs, again, by 
getting immediate tax credits. In 2014, they will be able to access the 
exchange, as will self-employed people. They will have the power of big 
business behind them as they go into those exchanges.
  I want to talk about public interest provisions. I wanted a public 
option, let me be clear, because I felt it would keep the insurance 
companies honest. But let me tell you what we have in here that are 
definitely public interest provisions. We expand Medicaid. That is a 
public plan to cover an additional 14 million people, and that starts 
in 2014. That is 1.5 million Californians. In my State, the Federal 
Government will pay the full fare for those added people for 3 years, 
and after that, far more than we get paid now. HHS will set the initial 
rules for the State exchanges. So those getting into the exchanges have 
to be fair. The OPM plan--that is the plan that will be part of the 
exchange--will be set up by the government, the Office of Personnel 
Management.
  Again, community health centers. A basic plan can be created by the 
States, which I think is very important. I thank Maria Cantwell for 
working so hard on that issue.
  If people tell you we do not have anything to do with public options, 
they are really not right. You have to look carefully at this bill.
  I want to talk about the deficit. We reduce the deficit between 2010 
and 2019 by $132 billion, and between 2020 and 2029, there is up to a 
$1.3 trillion deficit reduction, according to the Congressional Budget 
Office. That is a nonpartisan office. This bill reduces the deficit. I 
am going to say it one more time. This bill reduces the deficit. And 
the reason is, we invest in prevention, and that pays off. We finally 
will be able to say to the insurance companies: Stop your gouging. And 
that pays off. We do have competition now because we will have that 
special plan run by OPM, the State option Maria Cantwell put in there. 
This is why we see the reduction, including taking the fraud and the 
waste out of Medicare. We do not need fraud and waste.
  Here is how I want to close. Health care coverage for all Americans 
has been such an elusive goal for nearly a

[[Page 32944]]

century. If you look at Republican Presidents, Democratic Presidents, 
Republican Congresses, and Democratic Congresses, we have tried it over 
and over again, and the status quo has always prevailed.
  Our beloved friend, Senator Ted Kennedy, whom we miss so much, 
particularly during a time such as this, fought for health care right 
here on the floor from the moment he became a Senator in 1962 to the 
moment he died. In an op-ed in the Washington Post this past Friday, 
Ted Kennedy's wife Vicki wrote:

       Ted often said that we can't let the perfect be the enemy 
     of the good.

  I want to say to Vicki, she is exactly right. Each of us could write 
this bill our way. Believe me, if I wrote a bill, to me it would be 
perfect. But to my friend in the chair, she would say: I can make it 
better. And all of us could. This is the legislative process. This is a 
good bill.
  Vicki goes on to say:

       The bill before the Senate, while imperfect, would achieve 
     many of the goals Ted fought for during the 40 years he 
     championed access to quality, affordable health care for all 
     Americans.

  He is not here to urge us not to let this chance slip through our 
fingers.
  And she says:

       So I humbly ask his colleagues to finish the work of his 
     life, the work of generations, to allow the vote to go 
     forward and to pass health-care reform now. As Ted always 
     said, when it's finally done, the people will wonder what 
     took so long.

  I thank Vicki, not only for writing that wonderful editorial but for 
actually being in the Chamber when we took that first vote to break 
down this filibuster.
  I say to my colleagues, I am so proud that today we are moving closer 
to fulfilling the promise of health care for all Americans, including 
the 40 million Californians I am so privileged to represent. I thank my 
colleagues for all the work they put into this bill. I spent a lot of 
time on it myself, and this moment is very poignant. I hope we pass it.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KERRY. Madam President, let me begin by commending the Senator 
from California for an outstanding presentation regarding this 
legislation. I was listening to her in my office before I came over to 
the Chamber. I listened to her over here. She laid out in a very 
careful, deliberate, and thoughtful way the realities about this 
legislation before us. I thank her for a terrific presentation.
  I wish to pick up a little bit where she has left off. But let me 
inquire so I understand where we are. How much time is remaining on the 
majority side?
  The PRESIDING OFFICER. The majority side has 34\1/2\ minutes 
remaining.
  Mr. KERRY. I thank the Chair.
  Let me begin by saying I also listened to our colleagues on the other 
side of the aisle, particularly the Senator from South Dakota, just a 
little while ago. I was really struck by the chart they put up showing 
Medicare going up and up and up, and then they talk to Americans, 
basically scaring them, trying to say: If you pass this bill, it is not 
going to do anything to reduce the crisis in Medicare down the road.
  The reality is, that is all they present, is the scary picture of a 
future which they are not even describing accurately. They have had a 
year and a half--a year and a half--that we have been working on this 
legislation, since it was announced in the Finance Committee, on which 
I serve, and we held a day-long--I think a 2-day long conference over 
at the Library of Congress and within the committee where we began the 
work, laying the groundwork and foundation for a new Presidency and for 
the work that has gone on this year. Many of their Members took part in 
that. So there is no secret here as to where we are.
  This is a debate that has gone on in the United States of America 
since Harry Truman was President of the United States and before. We 
all know that President Teddy Roosevelt, a Republican, put before the 
country the notion that every American should be able to have their 
sickness dealt with.
  Nobody has ever contemplated that you ought to go bankrupt in order 
to have health care. But, as we know, we have more bankruptcies in 
America--health care bankruptcies--every year than any other nation on 
the planet. I think we are the only nation that really knows health 
care bankruptcy. The stories we have heard--countless stories.
  Earlier this morning--I guess to get my times correct--when we were 
here at 1 in the morning, we heard the majority leader talk about those 
very poignant, moving situations of individuals in Nevada. We heard the 
Senator from California. There are stories from every Senator, from 
every State. Yet it is only this dividing line, right here down the 
center of this Chamber--it is only the Senators on this side of that 
dividing line who seem to be prepared to try to address this issue. The 
fact is, the managers' amendment, which is now the pending business 
before the Senate, brings us even closer to being able to address many 
of the major concerns we have.
  Senator after Senator has come to the floor and described the way in 
which this bill does not do everything we want it to do. I have been a 
passionate supporter, as was Ted Kennedy and a lot of our colleagues, 
of a public component of this plan. Why? Because I believe that is the 
best way to create the kind of competitive pressure that will restrain 
a group of insurance companies that have shown no predilection to 
restraining themselves over these past years.
  If you are for the status quo, then you will vote no, the way our 
colleagues have voted. But the American people are not satisfied with 
the status quo. People in America understand that health care costs are 
breaking the backs of families. They are breaking the backs of 
businesses. They are a huge albatross around the neck of American 
competitiveness.
  Many of our companies have a harder time competing because there is a 
health care premium tax, if you will, for the uneven distribution of 
being sick in America. Obviously, if you are sick in America, you get 
care at some point in time. It may well be that point in time is when 
you are on your deathbed or when you are so sick that you finally go 
into the hospital, into an emergency room, and the emergency room 
becomes your first contact with the medical system or it becomes your 
primary care facility. We have almost 50 million Americans for whom 
that is true--50 million Americans who don't have health care. So they 
do not get an early screening, they do not get an early determination 
of what may be wrong with them. They do not get what somebody who has a 
health care plan gets, which may be a mammogram or a Pap smear or a PSA 
test for prostate cancer, or any number of evaluations, perhaps early 
detection of diabetes.
  We spend almost $100 billion in the United States for unnecessary 
dialysis and/or amputations that take place because people weren't able 
to go to a doctor earlier and learn that they had a type of diabetes 
that might have been able to be treated in a far less expensive and 
dramatic and personally costly way.
  The word ``history'' gets thrown around in the Senate probably more 
than it ought to. We often refer to something as being historic, where 
sometimes it is a reach. There is no question that we are on the 
threshold of an unbelievably historic moment in the Senate. This is 
history we are living here now.
  When I think of what we tried to do in 1993 and 1994, when President 
Clinton was in office and we tried to pass health care--we got beaten 
back by false advertisements--Harry and Louise--scare tactics, and I 
might add a plan that didn't quite pull the pieces together as 
effectively as we have. We have learned a lot of lessons since then. We 
have had many fits and starts, with children's health care, 
portability, and trying to deal with certain gender discrimination or 
other discrimination within the systems. We have gotten little pieces 
done. But all the time, the basics of the system have been without the 
reform necessary to bring down costs and make health care more 
accessible to more Americans.

[[Page 32945]]

  So I have no doubt we are reaching a moment of historic importance 
here. This is a moment where we are going to finally provide access to 
almost all Americans. Thirty-one million Americans are going to gain 
health care coverage through this legislation when we pass it, and that 
will bring us up to 94 percent.
  To give an example, in Massachusetts, where we passed health care 
reform a couple of years ago, we mandated that everybody be covered and 
we created a penalty for companies that don't offer the insurance, but 
we have a pool that helps provide coverage to people who can't afford 
it. We now have 97.6 percent of all our citizens covered in the State 
of Massachusetts. The fact is the premiums in the individual market, 
which is where it is most expensive for Americans to go out and buy 
health insurance, went down by 40 percent. The premiums went down by 40 
percent in Massachusetts for a quality of care that people love. The 
premiums in the rest of the country went up 14 percent. That is a 54-
percent spread in the cost of premiums between those who got health 
care reform and those who did not.
  That is precisely what we are going to be able to provide Americans--
beginning to provide Americans with this. One of the reasons we can't 
provide it as effectively as in Massachusetts is because there are 
certain things we do in Massachusetts that the other side, or some 
folks, have prevented us from being able to do here.
  Let me sort of lay it out here. There are a couple of things that 
bother me about this. We keep hearing from our colleagues--and I heard 
this from the Senator from South Dakota--that we are not going to be 
able to save money in the legislation we are going to pass. In fact, 
nothing could be farther from the truth. All of us know, as a matter of 
common sense, that many of the measures in this legislation are going 
to reduce the cost of health care, and one of the reasons is that the 
CBO analysis is generally limited to the Federal budget. It doesn't 
attempt to account for savings in the health care system that come from 
policies that are implemented through reforms.
  For example: The CBO found only $19 billion in government savings 
from transitioning toward post-acute bundled payments in Medicare. But 
recent research in the New England Journal of Medicine suggests that 
bundled payments--bundled payment, for somebody listening who doesn't 
understand, is when you take all the payments that come to a hospital 
or to the providers who provide the care, and the payments are all put 
together for the various services that you get and they have to decide 
how to provide you those services in a cost-effective way based on the 
whole universe of money that has been put on the table. It is different 
from what we do today, where we don't bundle it and say: Take care of 
this patient, and all of your various parts have to fit into a whole. 
Today, we pay each of the separate parts without relationship to what 
their connection is to the total care of a patient. It is unbelievably 
wasteful, ineffective, sometimes redundant, it is noncommunicative, and 
that is one of the reasons why in America we don't get the same 
outcomes for less money that people get in Europe or in some other 
countries.
  But we have learned from the New England Journal of Medicine, which 
is a highly respected medical journal, that the bundled payments for 
chronic diseases and for elective surgeries could reduce health care 
spending by as much as 5.4 percent from 2010 to 2019. Yet we don't 
credit for that savings. They do not talk about it. But common sense 
tells us, because we have seen it where they have done these bundled 
payments, that you are going to reduce the costs.
  In addition, even if such savings only applied to half of the 
spending in the health care sector, the result would be more than $900 
billion of savings over the next 10 years. If bundled payments get 
expanded beyond the post-acute care, and even half of the potential 
savings from bundled payments were realized in the Medicare Program 
during the upcoming decade, these savings would translate to an 
additional .2 percent of savings per year or reduction in program 
expenditures, and that would be more than $190 billion between 2010 and 
2019.
  I have talked about $1 trillion--$1 trillion--of savings that does 
not even get formally presented to the American people as part of this 
process because of bureaucratic technical rules about what the budget 
applies to. Everybody on the other side of this aisle knows, as a 
matter of common sense, if you look at the experience, the way it has 
already been proven in the marketplace, and if you apply your thinking 
to this, we are going to reduce the cost of health care.
  Similarly, large reductions in Federal health care expenditures are 
plausible from the combination of other delivery system reforms. A lot 
of Americans aren't aware of this, but here is what we have. 
Accountable care organizations. We don't have that today. Suddenly, we 
are going to have an accountability in the care organizations 
delivering service. That is going to provide savings.
  We have incentives to reduce hospital-acquired infections. One of the 
biggest single fears people have today in America when they go to the 
hospital is that they are actually going to get an infection in the 
hospital, and the chances of coming up with a staph infection or some 
other kind of infection are very real and very high. There are actually 
different practices between different hospital operations. I happen to 
know this on a personal basis because my wife recently had an operation 
in one hospital system and they had a certain procedure to try to deal 
with the MRSA infection, and a certain washing and disinfection process 
you went through, and I know other hospitals where they do not do the 
same thing.
  In addition, we are going to have health information technology 
reform adoption. There is going to be administrative simplification 
that would standardize and streamline insurance paperwork. I mean, if 
you go to the ATM machine and pull out some money, it is about a penny 
or half a penny per transaction. If you go to the hospital, where they 
do not have technology managing the records and people are doing it, it 
is about $20 to $25 per transaction to pull the records. In the age of 
computerization and information technology, it doesn't make sense, and 
all of us know that. But we also know that because we are putting money 
on the table and incentives in place to help do that, we are going to 
be able to get additional savings; all of the savings that are on top 
of the $1 trillion of savings I have already talked about, and none of 
which gets measured when our colleagues come to the floor to say what a 
terrible bill this is.
  CBO has also grossly underestimated savings in the past. I am not 
picking on CBO. They have had an incredibly hard job, and they have 
done an incredible job. They have been completely overworked on any 
number of efforts, where we have been asking for models and analyses. 
But it is automatic in a process that you are going to lose some 
things.
  According to the Generic Pharmaceutical Association:

       In 1984, it was predicted that the Hatch-Waxman Act would 
     save our country $1 billion in the first decade. Now, generic 
     medicines save more than that every three days.

  Every 3 days we do what was predicted to happen in savings every 10 
years. In the mid 1990s, the Congressional Budget Office released an 
analysis showing that in 1994--the tenth anniversary of the Hatch-
Waxman Act--annual savings of generics had reached approximately $8 
billion to $10 billion. The new data released showed that by 1999--15 
years after Hatch-Waxman became law--generics were generating $49 
billion in annual savings. In the last decade alone, generics have 
saved consumers, businesses, State and Federal governments $734 
billion.
  I haven't even talked about the wellness provisions or the prevention 
provisions that are in here. When we start getting all of America more 
tuned in to the things we can do to prevent diseases by taking actions 
in our lives, our lifestyles, in our diet, and

[[Page 32946]]

any other number of things, we can bring the cost of health care down 
in America.
  We keep hearing about the secrecy and how this legislation has been 
hidden from folks for a long period of time. Again, that is not true. 
There is nothing in this legislation that we haven't been working on or 
talking about or wrestling with in committee, out of committee, in 
hearings, in the public debate for over a year now. If the minority had 
taken a little less time to have press conferences and spending their 
time doing news conferences denouncing what they hadn't analyzed, they 
would have a better sense they might have been able to read the 
managers' amendment on the Internet for over a month--excuse me, the 
managers' amendment was on the Internet on Saturday, and many of us 
looked at it, because many of us have worked on provisions and we 
wanted to make sure they were in there. It wasn't hard to read it to 
see what was and wasn't included in it. In addition, the underlying 
bill has been posted on the Web for over 1 month.
  But the fact is the minority has made a fundamental political 
calculation here. They do not want to work with us. In all the time we 
were in the Finance Committee trying to mark it up, we never had people 
come to us--as I often have here in the 25 years I have been here when 
you are legislating seriously--and say, hey, if you include this or if 
you work this a little or if you tweak this, I think I could support 
this bill. There is just a fundamental political divide, a fundamental 
philosophical divide. We are looking at a party whose opposition to 
health care for Americans is not new. My colleague from California 
talked about it a few minutes ago. In 1935, they tried to kill Social 
Security and succeeded in preventing health care from being included in 
the bill at that time. They argued in 1935 the same thing they argue 
now.
  Madam President, may I ask how much time we have?
  The PRESIDING OFFICER. The Senator has consumed 20 minutes.
  Mr. KERRY. How much time do I have?
  The PRESIDING OFFICER. The majority has 15 minutes remaining.
  Mr. KERRY. And is that predesignated? Is the 15 minutes remaining 
predesignated, Madam President?
  The PRESIDING OFFICER. Not by order.
  Mr. KERRY. Madam President, in fairness, I was not aware; I thought I 
had the full amount of time, but I do not. I want the Senator from 
Connecticut to be able to share his thoughts also. Let me just say, and 
I will wrap it up here, that the insurance industry, which they sought 
to protect, survived the passage of the Social Security Act. In 1965, 
we passed Medicare. Medicaid came afterward. They opposed it. They 
opposed Medicare, one of the most important programs in the United 
States of America, that lifted countless numbers of seniors out of 
poverty. They said no. The insurance industry survived Medicare and 
Medicaid. They are doing very well.
  According to CBO, the gross cost of the managers' amendment is, over 
the next 10 years, $871 billion--less than the $1 trillion we started 
with in our committee. But it buys a lot. I will talk at some time, 
perhaps tomorrow or afterward, about what this bill provides in 
addition. But I think it is critical for people to follow the truth, to 
look for the facts, and to measure the reality of the positive ways in 
which this legislation will provide additional help to seniors, will 
reduce premiums for many Americans, will help people afford coverage 
who do not have it today, will spread risks throughout the system more 
effectively, will improve care and delivery within the hospitals, will 
prevent people from being denied insurance if they have a preexisting 
condition, will prevent them from being kicked off insurance they paid 
for and thought they had when they get sick and they suddenly get that 
letter that says: Sorry, you are not covered anymore, and families go 
bankrupt--that is over. That alone is an enormous step forward for this 
country.
  CBO has underestimated savings before.
  According to the Generic Pharmaceutical Association . . . ``In 1984, 
it was predicted that the Hatch-Waxman Act would save our country $1 
billion in the first decade. Now, generic medicines save more than that 
every three days.''
  In the mid 1990s, the Congressional Budget Office released an 
analysis showing that in 1994, the 10th anniversary of the enactment of 
Hatch-Waxman, annual savings from generics had reached approximately $8 
billion to $10 billion.
  The new data released showed that by 1999--15 years after Hatch-
Waxman became law--generics were generating $49 billion in annual 
savings.
  In the last decade alone, generics have saved consumers, businesses, 
and State and Federal Governments $734 billion.
  According to a December 14 report by the President's Council of 
Economic Advisors: CBO's analysis is generally limited to the Federal 
budget, and does not attempt to account for savings in the health care 
system more broadly from policies implemented through reform. For 
example, the CBO found only $19 billion in Federal Government savings 
from transitioning toward post-acute bundled payments in Medicare. 
However, recent research published in the New England Journal of 
Medicine suggests that bundled payments for chronic diseases and 
elective surgeries could reduce health care spending by as much as 5.4 
percent from 2010 to 2019. Even if such savings applied to only half of 
spending in the health care sector, the result would be more than $900 
billion of savings over the decade. If bundled payments were expanded 
beyond post-acute care and even half of the potential savings from 
bundled payments were realized in the Medicare program during the 
upcoming decade, these savings would translate to an additional 0.2 
percent per year reduction in program expenditures, or more than $190 
billion between 2010 and 2019.
  Similarly large reductions in Federal health care expenditures are 
plausible from the combination of other delivery system reforms, 
including: Accountable care organizations, incentives to reduce 
hospital-acquired infections, health information technology adoption, 
and administrative simplification that would standardize and streamline 
insurance paperwork. This will help cut down on the $23-$31 billion 
time cost to medical practices of interacting with health plans and 
their administrators.
  Another potentially significant cost saver within the Senate bill is 
the Independent Medicare Advisory Board--IMAB. The IMAB would recommend 
changes to the Medicare program that would both improve the quality of 
care and also reduce the growth rate of program spending. The CBO score 
of the Senate bill estimates that the IMAB would reduce Medicare 
spending by $23 billion from 2015 to 2019, with the savings likely to 
continue in the subsequent decade. The IMAB has the potential to 
increase the savings from many of the delivery system reforms described 
above, which may not be fully captured by the CBO estimates for the 
reasons previously mentioned.
  Taken together, the combination of Medicare- and Medicaid-related 
provisions in the Senate's Patient Protection and Affordable Care Act 
are estimated to reduce the annual growth rate of Federal spending on 
both programs by 1.0 percentage point in the upcoming decade and by an 
even greater amount in the subsequent decade. These savings would 
increase national savings and improve the long-run performance of the 
U.S. economy.
  The PRESIDING OFFICER. The Senator from Connecticut is recognized.
  Mr. LIEBERMAN. Madam President, I rise to declare and explain my 
support for the Patient Protection and Affordable Care Act. First, I 
commend Senator Reid and all those who worked so long and hard, 
including my friend and colleague from Connecticut, Senator Dodd, for 
all they have achieved in this legislation. The truth is, no piece of 
legislation, as significant and

[[Page 32947]]

complicated as this is, could possibly be totally satisfying to every 
one of us. In the end, each one of us has to ask ourselves: Do the 
positives in this legislation substantially outweigh the negatives? Are 
the things we like in the bill greater than the things that worry us? 
For me, the answer to both these questions is yes, because this bill 
makes real progress on the three important goals I have had, and I 
think most people have had, for health care reform.
  First, most of us have wanted to stop the continuous increases in the 
cost of health care that burden every individual, family, business, our 
Government, and our economy. Second, we have wanted to regulate 
insurance companies to provide better protections for consumers and 
patients. Third, we have wanted to find a way to make it easier for 
millions of Americans who cannot afford health insurance today to be 
able to buy it tomorrow. I believe this bill makes real progress in 
achieving each of these three goals. Most importantly, it does so in a 
fiscally responsible way.
  The Patient Protection and Affordable Care Act not only does not add 
to our national debt, through new health care delivery reforms it will 
help reduce the debt by $130 billion over the first 10 years, according 
to the independent Congressional Budget Office. That figure could 
multiply many times over during the second 10 years, thanks, in part, 
to the managers' amendment that incorporated stronger cost-containment 
proposals that several of us, across party lines, made to Senator Reid.
  In addition, it is very significant that, according to the Actuary at 
the Center for Medicare & Medicaid Services, this bill will extend the 
solvency of the Medicare trust fund for an additional 9 years. This act 
will also take substantial steps toward creating a health care delivery 
system that pays for the quality of the care patients receive rather 
than the quantity of care. I am proud to have worked with Members of 
both sides of the aisle to include amendments that would do that.
  For instance, Senator Collins and I introduced an amendment, parts of 
which were included in the managers' package, that will enhance 
transparency for consumers so they can make more informed decisions in 
choosing their health care providers and insurers. In fact, our 
amendment will create Physician Compare, a new Web site where physician 
quality measures that exist now but are not known by the rest of us 
will be posted for everyone to see and to use in the choice of 
physicians. This will also create incentives, we believe, for doctors 
to provide high-quality, more efficient care.
  I also cosponsored an amendment introduced by Senator Warner and some 
other freshman Senators that will contain costs even more. This 
amendment creates prevention programs to help us understand how to 
effectively manage chronic diseases such as diabetes, and it requires 
prescription drug plans under Medicare Part D to offer medication 
therapy management services to beneficiaries so they can better adhere 
to their prescription treatments. All that is progress on the first 
goal that I and most others had, which is to reduce the cost of health 
care without compromising--in fact, improving--its quality.
  The second goal. If this bill passes, insurance companies, as Senator 
Kerry said, will not only not be able to deny coverage if an individual 
has a preexisting condition, they will not be allowed to rescind 
coverage if you become sick, which is the outrageous reality today. 
Thanks to changes made by the managers' amendment, insurance companies 
will also be required to spend more of the premiums they collect on 
medical expenses for patients rather than on administrative costs and 
profits. That is real progress on the second goal I mentioned.
  As for the third goal, the fact is attested to by the CMS Actuary and 
CBO, 31 million more Americans will be able to have health insurance as 
a result of this legislation. We say that so often I think we forget 
the power of it--31 million people who do not have health insurance 
today will have it after this bill passes. That is a giant step forward 
for our society. It is not only the right thing to do, but it will also 
eliminate the so-called hidden tax that each of us who has health 
insurance today pays in higher premiums when someone who has no health 
insurance gets sick and goes to the hospital to be treated. That is 
real progress on the third fundamental goal of health care reform that 
I mentioned.
  Is there anything in the bill that worries me? Of course, there is. I 
would say, most of all, I worry that we, and future Congresses, will 
not have the discipline to keep many of the promises we have made in 
this bill to control costs by transforming the way health care is 
delivered because some of these reforms are controversial and they are 
going to be opposed by some health care providers and health care 
beneficiaries. Without the kind of discipline I have just mentioned, 
this bill will add to our national debt or increase taxes. Neither of 
those results is acceptable. If we stick to the contents of the bill, 
this bill will cut health care costs and it will reduce our national 
debt.
  In my opinion, our exploding national debt is the biggest domestic 
threat to our country's future. That is why I have said this bill must 
reduce that debt, not increase it. Accumulated debt is currently over 
$12 trillion, with our budget office estimating an additional $9 
trillion added in the next 10 years. That is unprecedented in our 
history. We are running up to the time when we can see a moment 
possible that we never thought would be possible, when our capacity as 
a nation to borrow will be imperiled, when we will have to raise 
interest rates so high it will constrict our economy and send us back 
into a recession, worse than the one we are coming out of now.
  We cannot bring the fiscal books of our Government back into balance 
by only making the health care system more cost efficient, but we will 
never control our national debt without doing so. Medicare is in a 
particularly perilous condition today. Without reform, the Medicare 
trust fund will be broke in 8 years--broke. With tens of millions of 
baby boomers reaching the age of eligibility, we simply must protect 
Medicare so it remains a viable program for both current and future 
generations.
  This leads me to my firm opposition to the creation of a new 
government-run insurance program and to lowering the age of eligibility 
for Medicare to 55 years. That opposition was rooted in my very serious 
concerns about our long-term national debt and the fragile fiscal 
condition of Medicare. For any new government-run insurance program, 
including the Medicare extension-expansion idea, the moment premiums do 
not cover costs the Federal Government--that is Federal taxpayers, the 
American people--would have to pay the difference. That could easily 
put our Federal Government and the taxpayers on the hook for billions 
and billions of dollars in future liabilities and further jeopardize 
the solvency of Medicare.
  Because of the insurance market reforms in this bill and other 
measures--the creation of a new system of tax credits and subsidies for 
people making up to 400 percent of poverty--the creation of a new 
government-run health care, the so-called public option or the 
expansion of Medicare to people under 65 is not necessary. Neither 
proposal would extend coverage to one person who will not be benefited 
by the new provisions of this bill, neither the public option nor the 
expansion of Medicare. Yet both proposals would, in my opinion, lead to 
higher premiums for the 180 million people who have insurance today and 
are struggling to afford the health insurance they have now because of 
cost shifting.
  According to studies by the CBO, a new government-run insurance 
program, a public option, would actually likely charge higher premiums 
than competing private plans on the exchange, and expanding Medicare to 
cover people 55 years or older would lead to additional cost shifting.
  I know the removal of the public option from the bill in the Senate 
disappointed and angered many Members of the Senate and the House, 
while I

[[Page 32948]]

know it pleased and reassured others. I wish to say to those who were 
not happy about the removal of the public option from this bill that I 
believe President Obama never said a public option was essential to the 
reform goals he set out to achieve and that most of us have. When the 
President spoke earlier this year to the Joint Session of Congress, he 
said a public option is ``an additional step we can take.'' An 
additional step, he said, but not an essential one. Then, he added, 
``The public option is only a means to that end.'' He concluded that we 
should remain ``open to other ideas that accomplish our ultimate 
goal.''
  I am confident this bill accomplishes the goal the President and most 
of us set out to achieve without the creation of a brand-new 
government-run insurance company or the further weakening of Medicare. 
This bill, as it appears it will emerge from the Senate, is delicately 
balanced. I understand the normal inclination in a conference committee 
with our colleagues in the House is to split the difference. But 
splitting the difference on this bill runs a real risk of breaking the 
fragile 60-vote Senate consensus we have now and preventing us from 
adopting health care reform in this Congress.
  That would be a very sad ending. Rather than splitting our 
differences, I hope the conferees will adopt our agreements so we can 
enact health care reform this year. The rules of the Senate require 60 
votes to end debate on a conference report.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. LIEBERMAN. I ask unanimous consent for an additional moment, 
maybe 2 moments, to complete my remarks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. LIEBERMAN. Each Member of the Senate will have to decide once 
again when this bill emerges from the conference whether he or she 
wants to be one of the 60 votes necessary to take up and pass the 
conference report. In this case my own sense of the Senate is the same 
as that expressed in the last few days by Senators Conrad, Nelson, and 
others. If significant changes are made to the Senate bill in 
conference, it will be difficult to hold the 60 votes we now have. I 
have two priorities that will matter a lot to me. The first is to 
continue and maintain the health care reforms that will improve the 
cost-effectiveness of our health care system and help reduce the 
national debt. Second, I hope there will be no attempt to reinsert a 
so-called public option in any form in the conference report. That 
would mean I will not be able to support the report.
  I want to support it. I believe I am not alone in that opinion among 
the 60 who supported the bill last night. Our exploding national debt 
is the biggest threat to our Nation's future. That means we must begin 
to make politically difficult decisions to reduce our debt. That means 
saying no to some groups and some ideas, including some we would 
otherwise support, because we simply cannot afford them.
  A final hope about the conference report. Perhaps some will say it is 
naive. I hope the conferees will find a way to produce a report that 
can be supported by some Republican Members of the Senate and House. It 
is a sad commentary on this moment in our political history that so 
major a reform will be adopted with no bipartisan support. Hopefully 
the conference will find a way, difficult as I know it might be, to 
conclude this long legislative journey with a bill that is not only 
worth supporting, as I believe the Senate bill now surely is, but also 
engages the support of Members of both parties.
  I yield the floor.
  Mr. ENZI. I ask unanimous consent that our time be extended in the 
same amount as their time was extended.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ENZI. I yield myself 15 minutes.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. Mr. President, the majority has voted to cut off further 
amendments to this bill. Senator Reid has used a procedural tool that 
prevents Republicans from offering amendments. Several of my Democratic 
colleagues have come to the floor to argue that Republicans don't have 
any ideas on how to improve the bill. Nothing could be further from the 
truth. Republicans have filed over 200 separate amendments. Yet the 
majority is refusing to allow us to vote on any. On a bill that will 
affect the health care of every American and one sixth of the Nation's 
economy, the majority has not allowed us to have more than 10 votes to 
try to improve the bill.
  This bill needs to be fixed. We know this bill currently will cut 
Medicare, raise taxes, and increase insurance premiums. If we had the 
chance to offer amendments, I believe we could make changes to fix the 
problems. I filed nine amendments, but I have not been allowed to offer 
any. I believe any reform should reflect the following core principles: 
reducing health care costs so that all Americans get the quality, 
affordable care they need, ending discrimination based on preexisting 
conditions, ensuring everyone has access to at least catastrophic care, 
preserving the right of patients to choose the doctors and health 
insurance plans that meet their needs, eliminating junk lawsuits and 
reforming our medical liability system, reducing health care costs for 
all Americans, improving patient safety, encouraging incentives for 
healthy behaviors by allowing insurers to charge low premiums to people 
who eat healthy, exercise regularly, and abstain from tobacco use, 
protecting Medicare for seniors by ensuring that any savings found in 
Medicare, a program that is going broke, are used to strengthen that 
program, not to create new entitlements, and helping all Americans 
afford health care coverage by fixing the flawed Tax Code so that all 
Americans can get tax benefits for purchasing health insurance.
  Unfortunately, the bill fails to do these things. I know most Members 
agree on those principles for reform. The hard part is making the 
principles come to life by translating them into bill language. I did 
that a few years ago when I introduced 10 steps to transform health 
care. Once the bill was introduced, I went on a tour of Wyoming in 
March of 2008 and hosted town meetings to talk about health care to my 
constituents. Some of the ideas I included in my 10 steps plan I also 
filed as amendments to the Reid bill. We need to end discrimination 
based on preexisting conditions. No one that has at least catastrophic 
coverage should be denied coverage for a preexisting condition. 
Everyone should have catastrophic coverage, but no one should be forced 
to buy anything. If someone does not at least have catastrophic 
coverage, then they should have to pay more if they want coverage in 
the future.
  Everyone should get the choices for health care that Senators get. 
Senators get to choose between competing private plans. So should all 
Americans. Senators get the same choices as any other Federal employee. 
No more, no less. The janitor in the building, the mailman, the forest 
ranger, we all get the same choices. All choices are from private 
insurance. The Federal Government does not have its own plan. Like 
other employers, the Federal Government does pay part of our health 
care, but not all of it. Our choices allow us to pick a plan with a 
higher premium at a lower deductible or a plan with a lower premium and 
a higher deductible. Everyone should have these same choices, but they 
would have to work for a company willing to make a contribution to be 
personally willing to make that contribution and pay the remaining 
premium and deductible.
  No matter how the health care reform bill comes out, there will not 
be free insurance. Everyone will pay something. The amount we pay 
should have a relationship to the choices we make. Insurance costs will 
only come down if we are encouraged to make the best choices.
  Speaking of choices, there is no reason shopping for health insurance 
should be any more complicated than purchasing an airline ticket. 
Everyone should be able to fire up their computer and look up health 
insurance options as they look up airline flights. Each State should 
set up a Web site or an exchange where consumers can find

[[Page 32949]]

the listing of all the health insurance plans sold in their State. The 
public should be able to pick their health insurance using the 
information on the Web site. Each health plan would list what is 
covered, the premium, the deductible, and the copay, not what 
Washington says they have to put on there. Every insurance company 
should be allowed to list their plan on any exchange, and the State 
could certify whether the plans meet the minimum requirements and 
whether subsidies could be used for those plans. There could also be 
ratings for how well the company provides for its insured customers, 
but people could buy from any company, having been warned.
  Everyone could use the transparencies of the exchange to find the 
insurance that best suits them. Transparency would also bring the costs 
down. Another thing that will bring down cost is changing the system 
from one that provides sick care to one that provides health care. One 
way to do this is to focus more on preventing preventable diseases. We 
know that incentives to encourage changes in behavior can result in 
lower costs for patients and employers. We know this because 70 percent 
of all health care costs are driven by behaviors. If you provide 
incentives to change those behaviors, you have a potential decrease in 
cost of 70 percent of all of the health care costs for an organization.
  Companies such as Safeway have designed plans that focus on personal 
responsibility and provide targeted incentives that lead to behavior 
changes that can reduce the risk of developing four of the most costly 
chronic conditions. Safeway's model, focused on four chronic 
conditions, can be attributed to 75 percent of all health care costs: 
Cardiovascular disease, which is 80 percent preventable; cancer, some 
types are 60 percent preventable; type 2 diabetes, which is 80 percent 
preventable; and obesity. As a result, Safeway has seen their health 
care costs remain flat over the past 4 years, while other employers 
experience annual cost increases as high as 6.3 percent. This is a huge 
accomplishment for Safeway and its employees, and the employee 
satisfaction is fantastic. Senator Harkin and I had an amendment that 
would do that. It was inserted into the HELP Committee bill and then 
pulled out without talking to us before it was printed in September. 
Never heard of that being done to Senators before.
  Health care reform legislation should include the necessary 
provisions to ensure that companies can continue to provide successful 
prevention programs that lead to better health and lower costs but also 
allow those programs to be replicated across public and private health 
programs. We should encourage these programs and allow people to reap 
the benefits of better health outcomes and lower health costs. 
Additionally, people who smoke should have to pay more. People who 
don't smoke should pay less. People should be encouraged to quit 
smoking, start exercising, and eat healthy. To put it simply, allow 
folks who follow healthy practices to pay less for their health 
insurance.
  People should be able to buy insurance across State lines. Companies 
should be able to sell insurance anywhere in the United States. 
Policies should be listed on the State exchanges with a disclaimer 
stating the policy is an out-of-State policy. The exchanges would also 
say whether the policy meets minimum credible standards according to 
Washington and the State. Insurance commissioners in both the insurance 
company's State and consumer's State, each get their usual amount for 
the sale--originators, because they can be consulted, and purchaser 
State, as they have to handle complaints.
  We need to help small businesses. I have been working on health care 
reform for some time. Small business owners are seeing their insurance 
premiums go up and up every year. They need real help. What they don't 
need is for the Federal Government to make their insurance even more 
expensive. CBO says the Reid bill will drive up insurance costs for 
small businesses. I have proposed a bill that CBO scored as saving 
small businesses money by lowering their health insurance premiums by 
up to 6 percent.
  Small business health plans allow businesses to join together through 
their trade association across State lines even nationwide so they can 
form big enough purchasing pools to effectively negotiate with the 
insurance companies and providers. Ohio has enough people they were 
able to do this within their State. It is effective. It brought down 
the cost of health care. They were able to save 23 percent just on 
administrative costs. They were sure if I could get my bill through, 
they would save even more by going across State borders. That is one 
that has been in the lab. It has been proven to work. Not in the bill.
  Small Business Health Plans, which was S. 1955, drafted by myself and 
Senator Nelson of Nebraska, former Governor and insurance commissioner, 
was voted out of the committee in March 2006. On May 2006, cloture on 
the bill was not allowed in the Senate by a vote of 55 to 43. I know 
how tough health care reform is to pass. I had a majority of the votes 
but not enough to begin debate. At the same time, Senator Snowe was 
poised to do a single amendment that would have solved the objection 
for 80 percent of those who voted against it. Without cloture, that 
amendment could not be offered. The Snowe amendment would have solved 
the question of what health plan mandates would be required. The desire 
for mandate clarification was the objection that had the disease groups 
working against the bill. The insurance companies worked against the 
bill and successfully defeated other versions called associated health 
plans for over a decade. I was able to neutralize much of the insurance 
lobby.
  By creating Small Business Health Plans, we can put small business 
owners in the driver's seat instead of the Federal Government or 
insurance companies. Through their associations, small business owners 
will have the kind of clout in the marketplace needed to negotiate 
high-value and high-quality health insurance for their members on a 
regional or even national basis.
  Additionally, throughout the health care debate, we have heard 
Democrats say we need a public option in order to keep insurers honest 
and to have more choices for Americans. However, the only place where 
we don't currently have competition is for the millions of Americans 
who are currently trapped in the Medicaid Program. Democrats believe it 
is OK to lock 54 million poor American people into Medicaid and have 
them languish in a system that is broken and they are unwilling fix. 
Their solution is to keep adding more Americans to this broken system. 
A 2007 Wall Street Journal article stated that Medicaid beneficiaries 
have poorer health than their peers with private insurance. A study 
published in the Journal of the American College of Cardiology found 
that Medicaid patients were almost 50 percent more likely to die after 
coronary artery bypass surgery than patients with private coverage. 
Merritt Hawkins found that in 15 major metropolitan areas and in seven 
particular cities, including Washington, DC, Medicaid acceptance was 
below 50 percent.
  A 2002 MedPAC report stated that 40 percent of physicians--let me 
repeat that: 40 percent of physicians--will not treat Medicaid patients 
because of their concerns about reimbursement and the time and added 
cost of completing the billing paperwork. Even the Office of the 
Actuary at the Centers for Medicare and Medicaid Services has stated 
that providers will accept more patients with private insurance than 
government-run health care due to the more attractive private physician 
payment rates. If you cannot see a doctor, you do not have insurance, 
no matter what the special name.
  As we increase dramatically the number of people eligible, we should 
find a way to offer them regular insurance so they do not have the 
stigma of being on Medicaid. They should be able to choose between the 
usual Medicaid and a private policy with a subsidy.
  Unfortunately, the Reid bill expands Medicaid, and the reason is 
because it is cheap. According to the Congressional Budget Office, it 
costs 20 percent

[[Page 32950]]

more to cover a person in the exchange, funded by Federal dollars, than 
through Medicaid, which is shared between Federal and State 
governments.
  One of my amendments would change all of this. Senators and their 
staffs all have the ability to choose between competing private plans, 
and I believe we should give that same kind of choice to low-income 
Americans. Instead of trapping people in a broken Medicaid Program, my 
amendment would provide individuals who would otherwise be enrolled in 
Medicaid through the expansion in this bill the right to choose to be 
covered by Medicaid or a qualified private health plan offered through 
their State exchange. Every American should be able to choose to enroll 
in private insurance, and my amendment would provide real choice access 
to a network of physicians and fix this problem. It would also assure 
them they would have coverage for an entire year, not just while their 
income fluctuates.
  On the topic of expanding government programs, I would also like to 
mention that if you save money in Medicare, it should only be used to 
help Medicare because it is already going broke. The current bill takes 
money from Medicare and uses it for other government programs. This 
bill takes $466 billion from Medicare and uses it to start new 
entitlements that have nothing to do with Medicare. Yet they start a 
new commission to figure out where to make additional Medicare cuts in 
order to keep the system going--doesn't that seem counterproductive--
after limiting where the cuts can come from because of hidden deals to 
get support for the bill.
  Whatever we do has to reduce costs for all individuals and be deficit 
neutral. It has to truly be paid for. Why does it have to be paid for? 
Because America is going broke. We have maxed out the credit cards, and 
now we are driving down the value of our money. We have to use honest 
cost, not gimmicks such as the doc fix delay or collecting revenues 
before the benefits kick in and showing years of revenue for a shorter 
time benefit.
  What ways can the government pay for anything? Unfortunately, they 
can cut benefits, cut payments to doctors and other providers, increase 
taxes, or cut waste, fraud, and abuse--which government seldom does and 
even more seldom does effectively--or, more honestly, allow a checkoff 
for donations to other people's insurance--perhaps even a tax-free 
donation--so people who want a bigger role in seeing that everybody has 
insurance could directly participate. People who argue that it is 
imperative we extend health benefits to everyone should put their money 
where their mouth is. People should have an opportunity on their income 
taxes to make an instantly deductible gift to the health care of 
others. If the deductible size of the gift is a refund, then they would 
not have to include a check.
  On the subject of taxes, taxes have to be fair to everyone. Right 
now, big companies can write off the health care they provide their 
employees, so those employees are getting health care with zero income 
tax. Individuals who buy insurance pay income tax on all the money they 
use to buy insurance. That is not fair.
  I have covered just a few of the ideas I have. I have several more 
ideas I have been talking about time and time again, none of which show 
up in the bill. These meet the promises that were made. The bill does 
not meet the promises that were made.
  Health care is too complicated and encompassing to be done by a 
single bill. I have never worked on a bill that affects 100 percent of 
America. Adequately done, rather than assigning details to agencies, a 
comprehensive bill has to contain details. Assigning the tough parts to 
the Secretary of Health and Human Services makes it easier to 
legislate, but you don't know what the final outcome will be. Done in 
smaller incremental steps, the bill would be more understandable. More 
importantly, with the huge, more comprehensive bill, the more people 
who each don't like a particular part will defeat the whole bill over a 
few parts.
  We need to start over. We need to pursue a step by step, bipartisan, 
approach. We need to match up a Republican idea with a Democrat idea. 
We need to leave out a Republican idea and leave out a Democrat idea. 
Pursing this type of strategy, what I call the 80-percent rule, would 
likely mean broad support from both sides. This would mean that the 
rigid ideologies of both sides would oppose such a bill, but I am 
confident that majority of the American people would support a bill 
like this.
  We need health care reform, but it has to be done the right way. The 
best way to reform our health care system is to do it step by step. We 
need to start by focusing on the issues where we already have broad, 
bipartisan agreement.
  I know how to pass bipartisan legislation. Since I came to the Senate 
13 years ago, I have worked with both Democrats and Republicans to 
reform our Nation's health care system. Over my years in the Senate, 
there have been several times when I have worked across the aisle to 
get health care bills signed into law.
  When I joined the Senate, the Health, Education, Labor, and Pensions 
Committee was one of the more contentious committees. I believe that 
people can agree on 80 percent of the issues 80 percent of the time 
and, if they leave the other 20 percent out, they can get a lot done. 
With that in mind, Senator Kennedy and I worked to make it one of the 
most productive and bipartisan committees, with a substantial number of 
bipartisan bills signed into law each year.
  Whether it is the reauthorization of the National Institutes of 
Health or the renewal of the Ryan White and PEPFAR programs for people 
with HIV/AIDS here and abroad, I am committed to working across the 
aisle on issues of importance. Working together, we got patient safety, 
mental health parity, and genetic nondiscrimination legislation over 
the finish line. These proposals had been pending for years. We were 
also able to have a strong bipartisan bill to overhaul the drug safety 
functions at the FDA. By working together, instead of against each 
other, we can achieve passage of many more pieces of critical 
legislation.
  Everyone agrees we need real changes that will allow every American 
to purchase high-quality, affordable health insurance. Not a single one 
of my Senate colleagues on either side of the aisle supports the status 
quo. The argument that Republicans support the status quo is simply 
false. We understand that the current system fails too many Americans. 
We want to support reforms that will provide real insurance options to 
all Americans and help lower the cost of that insurance.
  But I have said from the start of this year, and frankly throughout 
my 13 years in the Senate, true reform should be developed on a 
bipartisan basis, so that the legislation will incorporate the best 
ideas from both sides and will have the broad support of the America. 
That should be a prerequisite for any proposal that will affect the 
nearly 20 percent of our Nation's economy and the health care of every 
American.
  We have only had 10 votes on Republican amendments. It is not because 
Republicans agree the status quo is acceptable or because we think the 
health care system works fantastically; quite the opposite. Republican 
Members have filed 223 amendments to this bill. Unfortunately the 
majority leader has blocked us from offering our amendments.
  This bill is too important to get wrong. We need the opportunity to 
improve this bill, and I would urge my colleagues in the Democrat 
leadership to allow us the opportunity to do so.
  Madam President, I ask unanimous consent that an editorial by David 
Broder, ``One Is the Loneliest Number for President Obama,'' be printed 
in the Record. It mentions some of the editorials and key points of 
editorials that I put in my speech last night.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

            One Is the Loneliest Number for President Obama

                           (By David Broder)

       In the last year or so of George W. Bush's second term, 
     commentators used to talk a

[[Page 32951]]

     lot about the conspicuous scarcity of other Republicans 
     willing to stand up and defend him. I never thought we'd see 
     Barack Obama face the same problem before his first year was 
     over.
       But as Obama's approval scores (50 percent in the latest 
     Washington Post-ABC News poll) sink, it is getting harder and 
     harder to find a full-throated supporter of the president.
       You need go no further from here than the op-ed page of 
     Thursday's Washington Post to see what I mean. Time was, and 
     not all that long ago, when the Post was thought of as the 
     ``liberal paper'' in Washington, a reliable advocate for the 
     kind of policies pursued by Democratic presidents.
       Well, in the lead article on the op-ed page, a well-known 
     member of the president's party said that Obama's prize piece 
     of domestic legislation, the health care reform bill, has 
     been so compromised that as it stands, ``this bill would do 
     more harm than good to the future of America.''
       ``If I were a senator,'' wrote Howard Dean, former governor 
     of Vermont and the chairman of the Democratic National 
     Committee during Obama's run for the White House, ``I would 
     not vote for the current health-care bill.''
       Dean, who had been signaling his apostasy for some time, 
     was far from alone in clobbering Obama, just as the president 
     and Senate leaders were struggling to line up the 60 votes 
     needed to pass the ever-changing legislation.
       Across the Post's prized real estate, conservative 
     columnist George F. Will gloated that the more Obama argued 
     for the bill, the less the public supported it. And from 
     across the aisle, Matthew Dowd, a former Democrat who served 
     as chief strategist for the younger President Bush, offered 
     congressional Democrats the free advice that they would be 
     better off themselves if the Republicans managed to block 
     Obama's bill.
       It was left to my friend, E.J. Dionne, Jr., one of Obama's 
     most passionate journalistic advocates, to tell the Democrats 
     that they ought to mind their manners--and their words. The 
     increasing flak between moderate and liberal Democrats ``is a 
     recipe for political catastrophe,'' Dionne warned, his tone 
     suggesting that he thinks the Democrats are too far gone to 
     heed him.
       But this wasn't the worst I saw that day. The worst came in 
     a news report of the year-end news conference by House 
     Speaker Nancy Pelosi. Asked how she would deal with next 
     year's looming tests of congressional Democratic support for 
     Obama's decision to send 30,000 more U.S. troops into the 
     Afghanistan struggle, she said, ``the president's going to 
     have to make his case'' himself. Reminding reporters that she 
     had told lawmakers in June, when funding was approved for 
     17,000 additional troops, that it would be the last time she 
     would ever lobby her members to back such a step, she made it 
     absolutely clear she felt no obligation of party loyalty to 
     support Obama on the most important national security 
     decision he has made.
       The liberal legislator from San Francisco could not have 
     been plainer if she had added, ``You're on your own, 
     buster.''
       With this as an example from the No. 1 Democrat on Capitol 
     Hill, one has to wonder why liberal Democrats are so furious 
     about senators such as Joe Lieberman and Ben Nelson 
     negotiating their own deals with the White House on the 
     health care bill.
       I think Obama deserves more help than he is getting from 
     his fellow Democrats in Congress, given the boost he provided 
     them in the last election, the difficulty of the problems he 
     inherited, and the stiff-arm he has received from the 
     Republicans.
       But the reality is that, the closer the midterm election 
     comes, when they will be on the ballot and he will not, the 
     more members of Congress--and not just Pelosi--will judge 
     what is best for themselves and the less they'll be swayed by 
     Obama.
       He may feel lonely now, but he ain't seen nothing yet.

  Mr. ENZI. Madam President, I also ask unanimous consent that an 
editorial by George Will from the Washington Post titled ``The 
Indispensable Dispenser Opens Up'' be printed in the Record. It shows 
how Medicare is left up in the air after the Reid bill.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                  The Indispensable Dispenser Opens Up

                            (By George Will)

       Ryan Bingham has a unique way of describing his life.
       ``Last year,'' he says, ``I spent 322 days on the road, 
     which means that I had to spend 43 miserable days at home.'' 
     Home is an Omaha rental unit less furnished than a hotel 
     room. He likes it that way.
       Today he is where he feels at home, in an airport--glass 
     walls and glistening steel, synthetic sincerity and 
     antiseptic hospitality. Today he is showing Natalie, a 
     ferocious young colleague, how an expert road warrior deals 
     with lines at security screening:
       Avoid, he says, getting behind travelers with infants 
     (``I've never seen a stroller collapse in less than 20 
     minutes''). Or behind elderly people (``Their bodies are 
     littered with hidden metal and they never seem to appreciate 
     how little time they have left on earth''). Do get behind 
     Asians: ``They're light packers, treasure efficiency, and 
     have a thing for slip-on shoes.''
       Natalie: ``That's racist.''
       Bingham: ``I stereotype. It's faster.''
       Played with seemingly effortless perfection by the 
     preternaturally smooth George Clooney, Bingham is the cool 
     porcelain heart of the movie ``Up in the Air.'' It is a 
     romantic comedy, although Bingham begins immune to romance. 
     And the comedy is about pain--about administering it somewhat 
     humanely to people who are losing their jobs.
       Bingham is a ``termination engineer.'' He fires people for 
     companies that want to outsource the awkward, and 
     occasionally dangerous, unpleasantness of downsizing. His 
     pitter-patter for the fired--``Anybody who ever built an 
     empire, or changed the world, sat where you are now''--rarely 
     consoles. But with his surgeon's detachment, he is more 
     humane than Natalie, who says this:
       ``This is the first step of a process that will end with 
     you in a new job that fulfills you. I'd appreciate it if you 
     didn't spread the news just yet. Panic doesn't help 
     anybody.''
       A confident young cost-cutter from Cornell, her brainstorm 
     is to fire people by videoconferencing. She tells one 
     desolated man:
       ``Perhaps you're underestimating the positive effect your 
     career transition may have on your children. Tests have shown 
     that children under moderate trauma have a tendency to apply 
     themselves academically as a method of coping.''
       Bingham considers his low emotional metabolism an 
     achievement, and in motivational speeches he urges his 
     audiences to cultivate it: ``Your relationships are the 
     heaviest components of your life. The slower we move, the 
     faster we die. We are not swans. We're sharks.''
       The movie begins and ends with everyday people talking to 
     the camera, making remarkably sensitive statements about the 
     trauma of being declared dispensable. Some, however, recall 
     that the consequences included being reminded that things 
     they retained, such as their human connections, are truly 
     indispensable.
       The opening soundtrack is a weird version of Woody 
     Guthrie's ``This Land Is Your Land.'' This hymn to 
     Depression-era radicalism is catnip for people eager to 
     tickle a political manifesto from any movie that has a 
     contemporary social setting.
       But although ``Up in the Air'' might look like a meditation 
     on the Great Recession, it is based on a novel published in 
     2001, during the mildest recession since the Depression, and 
     written before that.
       You must remember: In 2006, the last full year before this 
     downturn, when the economy grew 2.7 percent and the 
     unemployment rate was just 4.6 percent, 3.3 million people 
     lost their jobs to the normal churning of a dynamic economy. 
     This ``creative destruction'' has human costs, but no longer 
     is optional.
       America has an aging population, and has chosen to have a 
     welfare state that siphons increasing amounts of wealth from 
     the economy to give to the elderly. Having willed this end, 
     America must will the means to it--sometimes severe economic 
     efficiency to generate revenues to finance the entitlement 
     culture. So ``Up in the Air'' is sobering entertainment for a 
     nation contemplating a giant addition to the entitlement 
     menu.
       ``Up in the Air'' is two mature themes subtly braided and 
     nuanced for grown-ups. One is the sometimes shattering sense 
     of failure, desperation and worthlessness that overwhelms 
     middle-aged people who lose their livelihoods. The other is 
     that such shocks can be reminders that there is more to life 
     than livelihoods.
       But not for Bingham. He is, in his fashion, content. In 
     E.M. Forster's novel ``Howards End,'' Margaret famously 
     exhorted, ``Only connect!'' Bingham would rather not.

  Mr. ENZI. Madam President, I yield the floor and reserve the 
remainder of our time.
  The PRESIDING OFFICER (Mrs. Shaheen). The Senator from South 
Carolina.
  Mr. DeMINT. Madam President, we have heard a lot about the 
unsustainable mountain of government debt, bureaucracy, and spending 
the Democratic majority intends to create in rushing their health care 
proposal through this Chamber. We have also heard a lot about how much 
of this they inherited. We need to remember that this Congress--both 
Houses of Congress--has been controlled by the Democratic Party for 3 
years now. The President does not write legislation or spend money; the 
Congress does. The only thing the Democratic majority has inherited is 
its own irresponsible spending.
  Saturday's release of the final Democratic bill only increases 
America's concern with this Congress, its shadow negotiations, and our 
growing debt.

[[Page 32952]]

  Early this morning, all 60 Democrats voted to force all the taxpayers 
of this country to pay for bailouts and special favors for several 
States. Rather than actually taking the time to put forth real health 
care reform proposals that would increase Americans' ability to buy and 
own health care plans they could really afford, this plan forces over 
15 million Americans onto yet another bankrupt entitlement program, 
Medicaid.
  While Medicaid is a State and Federal shared program, the Democratic 
majority saw fit for the Federal Government to pay 100 percent of the 
Medicaid Program in the State of Nebraska under this legislation at the 
expense of taxpayers in the other 49 States, who will now be forced not 
only to deal with the loss of their freedoms under this huge government 
takeover but to pay for special favors in other States.
  This State bailout is not the only downside of the majority's health 
care proposal; there is a laundry list we could go through. Just a few 
include that the working American taxpayers and their employers will be 
taxed $500 billion over the next 10 years, and the Congressional Budget 
Office has confirmed that nothing in this bill decreases the premiums 
for Main Street Americans.
  Seniors will see their Medicare benefits changed as a result of the 
$500 billion in Medicare cuts included in this bill, not to mention 
that this bill turns a blind eye to the physician payment system that 
is woefully underfunded and vitally necessary to maintain the Medicare 
Program and physician access for seniors. It does not matter how good 
the insurance is we give our seniors if they cannot find a doctor who 
will see them.
  Another alarming part of this bill is it will, for the first time in 
decades, force every American taxpayer to pay for abortion services.
  Frankly, after reading this bill, it seems the only Americans who are 
not going to be affected by the bill are Members of Congress, 
pharmaceutical companies, and insurance companies.
  Madam President, for all the mind-boggling numbers and devastating 
facts we have heard about the majority's government takeover of health 
care, this debate is about much more than health care. It is about how 
we find ourselves in a situation where we are debating the best way to 
give the government control over another big part of our lives and our 
economy.
  In the children's story of ``Hansel and Gretel,'' the children drop a 
trail of breadcrumbs as they walk through the forest so they will be 
able to find their way out of the woods. But when the birds eat the 
breadcrumbs, the children find they are lost in the dark and 
frightening woods.
  Well, lost in the woods is exactly where we find ourselves as a 
country right now. We know we are in trouble, but there is no clearly 
marked path to get us back to where we were, and it is plenty 
frightening.
  In the past year alone, this Federal Government has taken over two of 
our largest automakers, our largest insurance companies, the largest 
mortgage company, and hundreds of banks. It has bailed out Wall Street 
and attempted to stimulate the economy by taking $1 trillion out of the 
private sector and spending it on wasteful government programs. It has 
thrown taxpayer money at people to encourage them to buy new cars and 
houses. And it is looking at imposing massive new job-killing taxes on 
businesses in the name of reducing global warming--all in the middle of 
a snowstorm.
  One of the problems we have now in this country is, instead of asking 
if we should solve it, we are asking, how should we solve it? It is now 
considered a sign of admirable restraint to occasionally ask here in 
this Senate and in this Congress, how much should we spend? And somehow 
we started thinking that anything less than $1 trillion is a good deal. 
There is not a pothole in America that most Members of the Congress do 
not believe should be filled with an earmark from the Federal 
Government. There is not a bridge to nowhere, a flat tire, a skinned 
knee--there is nothing off limits for this Congress today.
  This matters not just because of our unsustainable debt and the huge 
amount of money we waste; it matters because every time we give a job 
to the government, we take away some control people have over their own 
lives, and we take away a little bit more of their freedom. In return 
for letting government try its hand at solving a problem, we as 
citizens cede our ability to try for ourselves to find a better way.
  It is awkward to admit it, but my colleagues in Congress have led 
this country into the woods, despite our oath of office. We swore to 
protect and defend the Constitution of the United States and to bear 
true and faithful allegiance to it. The Constitution prescribes a very 
limited role for the Federal Government. There is not a word in our 
oath or in the Constitution about most of what we do. As we have 
wandered off the path of liberty, there are few crumbs left of the 
Constitution in the Halls of Congress to lead us out of the woods.
  There is not a word in the Constitution about the government deciding 
what medical test private health insurers should pay for, nothing about 
the government deciding how much executives on Wall Street should earn 
or what kind of lightbulbs or cars we should buy. There is nothing 
about the thousands of parochial earmarks that fund local bridges to 
nowhere, golf courses, bike paths, sewer plants, and teapot museums. 
There is nothing about these or many other things in the Constitution 
because they have nothing to do with the proper role of the Federal 
Government in a free society. But these are exactly the kinds of things 
our government spends its time and money on, and we do not even 
question anymore why that is.
  Instead, it has gotten to the point where if we oppose the government 
doing anything, we are accused of being opposed to getting it done. 
That is patently absurd. If you really want to get something done and 
get it done right, the government is absolutely the last place we 
should turn.
  The tea parties, townhalls, and rallies affirm that the American 
people are rethinking the appropriate role of the government in a free 
society. Hopefully, their discontent will be demonstrated in the 2010 
elections. Only the American people can hold our elected Federal 
representatives accountable for fulfilling their oath of office. In the 
health care debate, this means deciding exactly what role the 
government should play to help people in the private sector find 
solutions, instead of creating a monstrous new bureaucracy that puts 
the government in charge of every decision.
  But this debate is about much more than health care. It is a battle 
for the heart and soul of America. It is a struggle between freedom and 
socialism, between free markets and a centrally planned economy, and 
between ``we the people'' and an entrenched class of elite politicians.
  The current debate over health care reform is a symptom of a bigger 
problem in Washington. But it can be the catalyst for a wider debate 
about the proper role of government in our lives. The same debate can 
lead us to a moment when Americans finally take a stand to return 
government to its proper place--and we can all start finding our way 
out of the woods.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from North Carolina.
  Mr. BURR. Madam President, I am going to be joined by a number of my 
colleagues, so I ask unanimous consent that we be able to have a 
colloquy during the remainder of our time.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BURR. Madam President, I think many Members have to ask: Why are 
we here? We are here because at 1 a.m. this morning, there was a 
cloture vote on the consideration of the Reid managers' amendment. I 
think it is important that we discuss what that means. It means there 
are going to be no more amendments, no opportunity for any Senator from 
any State to propose a change to the bill. At some point, we will have 
an up-or-down vote on exactly what Senator Reid has presented to us.

[[Page 32953]]

  But here is what we do know. We are going to steal $466 billion from 
Medicare. We are going to take that $466 billion away from hospitals, 
from hospice, from nursing homes, from home care, and, yes, a popular 
target up here--the insurance product many Americans have chosen, 20 
percent of the seniors, Medicare Advantage. We are going to eliminate 
that option. So this is one case where if you like your health care, 
you are going to lose it.
  The bill that we are considering and that will be voted on later this 
week raises $519 billion in new taxes and fees--$519 billion in new 
taxes. I might add for my colleagues, we are taxing tanning salons at 
10 percent. What in the hell does that have to do with health care? 
Well, the reason it is in there is because we dropped taxing Botox. 
Hollywood saw this was not advantageous to have Botox taxed, so when 
they dropped that, they had to find something else: poor tanning 
salons, small businesses in every community across this country. We are 
going to actually tax the majority of Americans the President said he 
would never tax: those under $200,000, the ones who can't afford to go 
to the beach every weekend; the ones who don't have a beach house. They 
are going to pay a 10-percent tax when they go to get a little bit of a 
tan. Well, when they do that, how far off are we from fining parents 
because we don't put a high enough SPF on our children, or are we going 
to start charging when we go to the beach because we get exposure to 
the Sun? That is what happens when the government becomes a more 
dominant role in health care.
  I might add: No doctor fix, something many of us have highlighted. In 
the bill, there was a 1-year fix. Doctors are going to be faced with a 
21-percent cut in their reimbursements after this next 2 months. There 
was a 1-year fix to it. It didn't do away with the problem. It didn't 
fix the whole problem. But now there is no 1-year fix. We have said in 
60 days doctors will be on their own.
  Yes, there were some special deals--the cornhusker kickback, the 
windfall for Nebraska. I have to admit that I was proud of my 
colleague, Senator Johanns, who came to the floor and said: Let me 
assure you, the people in Nebraska have never asked for something 
different than everybody else. They are willing to pay their share of 
the way there. They haven't asked for it to be free for them and cost 
everybody else.
  Yes, it will cost my constituents in North Carolina, and it will cost 
the constituents in Nevada--well, it won't in Nevada. I think maybe 
there is even a deal that affects them to some degree.
  Is it fair? No, it is not fair. The fact that it wasn't fair was 
called: ``That is compromise.''
  That is not compromise. We are here under an obligation to make this 
fair to all of the American people. But in this case, it is not.
  Yes, there are 31 million Americans who are going to have health 
insurance, 15 million of whom are delegated into Medicaid, the most 
dysfunctional delivery system that exists in the American health care 
system.
  Yes, there is, for many States, an unfunded mandate to those States 
because after 5 years, for most States, except for those who got these 
special deals, the States are going to be responsible for some portion, 
an average of 10 percent of the cost of Medicaid.
  Let me tell you what my Governor, Governor Bev Perdue of North 
Carolina, said earlier:

       The absolute dealbreaker for me as governor is a Federal 
     plan that shifts costs to the States.

  Well, we are shifting costs to the States, and she is nowhere to be 
found now. But the people in North Carolina, the taxpayers of North 
Carolina are going to continue to be charged for this expansion of 
Medicaid when that is the most inefficient place for us to have put 
these 15 million Americans who were promised health care.
  While we do all this, according to the Chief Actuary of the Centers 
for Medicare and Medicaid Services, CMS, 20 percent of our hospitals 
and nursing homes are going to go bankrupt. They are going to go out of 
business because as the Chief Actuary said:

       They would be unprofitable within the next 10 years as a 
     result of these cuts.

  Hospitals, nursing homes, at a time that our senior population is 
getting ready to explode as the baby boomers hit it, we are cutting 
$466 billion from Medicare, and we are starving the infrastructure of 
hospitals and nursing homes and hospice and home care.
  What is going to happen to the providers? The Chief Actuary, again, 
said if we pass this plan, the result is providers will be unwilling to 
see Medicare and Medicaid patients.
  Today, 40 percent of providers don't see Medicaid patients. Does that 
mean it is going to be 50 percent or 60 percent or 70 percent? We are 
ballooning a system that today is having a hard time finding providers. 
To most of us that doesn't make sense, but that is what the Senate is 
going to do.
  I might also add that the attempt was to expand coverage; and, yes, 
sure, in numbers, we are expanding coverage. But, if passed, the 
Congressional Budget Office says 8 million to 9 million individuals who 
currently have employer-based health care will lose that health care. 
Eight million to nine million who currently have their health care will 
lose their health care with the passage of this bill. The net-net is 
not real pretty, and when you look at the $2.3 trillion that health 
care costs, you have to ask yourself, where is the beef? Where is the 
value in this?
  As hospitals close, as nursing homes close, as providers don't see 
Medicare and Medicaid, ask yourself, have we really done something 
good? Chances are, you will find out if we do nothing, if we do 
nothing, we will actually save money in the health care system.
  The last fact: The Chief Actuary of Medicare said: If you pass this 
bill, the cost of health care will be $\1/4\ trillion more than if we 
did nothing.
  The President talked about bending the cost curve down. We are 
bending that cost curve up in this bill. We are bankrupting hospitals 
and nursing homes. We are chasing providers from seeing Medicare and 
Medicaid patients.
  There are not too many things we can point to that are great about 
this bill. That is every reason we should start over.
  I know my colleagues are here to join in and to offer some 
perspectives, and I would ask them to chime in.
  Mr. ENSIGN. Madam President, let me just summarize a few problems I 
see in the bill, and maybe even offer a few suggestions about what I 
think we can do in a bipartisan fashion--kind of this step-by-step 
approach many of us have been talking about--instead of this massive 
government takeover of our health care system.
  This is a--I have lost track--I think somewhere around a 2,700-page 
bill with incredibly complex legal language. In the 400-page amendment 
offered the other day, when I was sitting there listening to the 
reading of it, I can't tell my colleagues how many times I was 
listening to this and I thought: When the regulations are written to 
that particular small part of the amendment, it could be incredibly 
complex with all kinds of unintended consequences. I thought about the 
burdens on small business and the record keeping that small businesses 
are going to have in this bill.
  I think what is going to also happen with small business, there is 
going to be a great incentive--if you are a small business owner, the 
complexities are so much and you can get yourself in so much trouble, 
you know what, I am just going to pay the fine. I will write a check to 
each one of my employees, but I am getting out of the health care 
business. I am going to let them go out and find their own health care, 
whether through the government exchanges or whatever it is, but I am 
getting out. That is one of those unintended consequences that a lot of 
people haven't focused on.
  We talked a lot about this $500 billion-plus cut in Medicare. My 
colleague from North Carolina mentioned that. Some of the biggest 
places--I had two grandmothers who were in hospice. Hospice care is the 
most compassionate care we have today, and we are going to cut hospice 
care. That actually puts dignity back into dying. That is just 
unconscionable. The Congressional Budget Office says these cuts 
actually will be cuts in service because you

[[Page 32954]]

can't just take money out of the system unless you make them more 
efficient. These cuts don't make the system more efficient, they just 
take money out of the system, whether it is out of hospice or nursing 
homes or the home care, but also out of Medicare cuts.
  We know there is $120 billion in cuts to Medicare Advantage. The 
Congressional Budget Office said by 2016, 64 percent of the extra 
benefits, whether those are prescription drugs or dental coverage or 
vision coverage, the seniors covered under Medicare Advantage are going 
to be cut 64 percent because of this legislation.
  We also know there is around $500 billion in new taxes, and this is a 
complete violation of the President's promise during the campaign when 
he said not one dime in new taxes will be raised on those individuals 
making less than $200,000 or families making less than $250,000. Yet in 
this bill, of the $500 billion, 84 percent is paid by those people the 
President said wouldn't have their taxes raised by one dime.
  We also know, because the Senator from North Carolina talked about 
it, this massive Medicaid expansion--I think it was the Democratic 
Governor from Tennessee who said it was the mother of all unfunded 
mandates. Well, we have to look at this one way. If the sweetheart deal 
that was made by the Senator from Nebraska--and, by the way, I agree 
with you. Senator Johanns, who came to the floor, it takes a lot of 
courage to say it isn't about just helping my State; it is about 
thinking about the whole country as well. He isn't asking for 
something--which most Senators do around here, ask for something just 
special for the State that the rest of the States have to pay for--but 
he stood up with courage, and I think he deserves a lot of credit for 
that.
  But if all the other States now come back and say: We want the 
Federal Government to pay for our States and Medicaid, this bill is 
going to do one thing. It is either going to be a massive unfunded 
mandate on our States or this bill is going to massively balloon the 
Federal debt.
  Mr. COBURN. Madam President, I have a question for both the Senator 
from North Carolina and the Senator from Nevada. Can the State of 
Nevada or the State of North Carolina or the State of Nebraska or the 
State of Oklahoma be healthy if our country doesn't flourish? So no 
matter what we do for our own States, if, in fact, we are not thinking 
about the country as a whole, the best right thing for the country as a 
whole, none of our States can flourish.
  Mr. ENSIGN. I think the Senator from Oklahoma has made a wonderful 
point. Right now, my State is suffering terribly, not because of 
anything individually, such as we didn't get our fair share of 
something; my State is suffering because the whole economy is in the 
doldrums and because we are such a tourist economy, construction 
oriented, the housing industry, all of those things, and because the 
general economy went down, my State is suffering.
  So the Senator is exactly right. We should be looking at what is best 
for the entire country. As John F. Kennedy said: A rising tide raises 
all boats. Well, if the whole country is doing better, whether it is on 
health care or whatever it is, instead of looking for something 
individual for our States, you are exactly right. I think our 
individual States will do better if the whole country does well.
  Mr. COBURN. Madam President, I ask unanimous consent to have printed 
in the Record an article that appeared today. It is a quotation from 
the founder from the Daily Kos Web site. I will give it to the clerk in 
a moment. I wish to read a quote from it:

       I don't think this is a reform bill. I mean, I think it is 
     very clear this is not insurance or health care reform. What 
     it is is allowing more people, 30 million people, to buy into 
     an existing broken system. It is very important to keep in 
     mind that health insurance is not the same as health care. If 
     you go up to Massachusetts, they have a mandate as well. Last 
     year, in Massachusetts, 21 percent of the people who are 
     insured could not get health care because they could not 
     afford it.

  That is somebody who is very well respected on the majority side, and 
it is something we have been saying, and they are saying the same 
thing. The fact is, what we are going to do is put 15 million people 
into Medicaid that we know has worse outcomes, we know is an unfunded 
mandate on the States, and we know 40 percent of the doctors refuse to 
see them. So you are not going to get to choose the doctor you want to 
see. You are going to have State mandates in terms of what is available 
to you and what is not. So we have violated two of the key promises 
with which to reform health care.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                  Moulitsas: We'll Get Killed in 2010

       Markos Moulitsas, founder of the Daily Kos and an 
     influential leader of the Web-based political left, said 
     Sunday that Democrats are facing huge defeats in the 2010 
     elections because the Obama administration has alienated the 
     Democratic Party's liberal political base with its escalating 
     involvement in Afghanistan, and its failure to push for 
     universal healthcare.
       Speaking on NBC's ``Meet the Press,'' Moulitsas offered a 
     bleak scenario for House and Senate races next year.
       Excerpts:
       Mr. Gregory: Markos Moulitsas, I want to start with you. 
     You heard David Axelrod say this in keeping with the 
     president's principles; it is in keeping, the compromise on 
     health care, with the way the president campaigned on this. 
     And this is the bill, essentially, the reform that Americans 
     deserve. What do you say?
       Mr. Markos Moulitsas: Yeah, I don't think this is a reform 
     bill. I mean, I think it's very clear, this is not insurance 
     or healthcare reform. What it is, it's allowing more people, 
     30 million people, to buy into the existing broken system. 
     It's very important to keep in mind that healthcare insurance 
     is not the same as health care. Insurance, not the same as 
     care, if you go up to Massachusetts, they have a mandate as 
     well, and last year 21 percent of people in Massachusetts 
     could not get health care because they could not afford it. 
     Even though they had insurance, the premiums--not the 
     premiums, the deductibles, copays and out-of-pocket expenses 
     were too high. So really, this isn't reform. It's expanding 
     the system, it's almost rewarding the existing system. Now, 
     what is important about this is that it actually puts the 
     federal government, plus America on the place to say health 
     care is a right, it's not a privilege to just those who are--
     who can afford it or who are lucky enough to have a good job 
     that has good benefits. But as far as reform goes, I think 
     this is a long battle that we have ahead of us.
       Mr. Moulitsas: Well, you can't talk about health care and 
     Afghanistan being distractions. They're the reasons that 
     Obama won the White House and Democrats won control of 
     Congress, including big, massive support from independents. 
     Independents know what they were voting for when they voted 
     for Obama and the Democrats. I think the problem with Obama's 
     numbers and, and Congress' numbers is that people voted for a 
     Congress and a president that was going to take on entrenched 
     interests. Now, Republicans had jumped off the Obama 
     bandwagon from day one. They were never on board. 
     Independents have sort of been unhappy because I think 
     independents really want results, and we haven't seen a lot 
     of results. We've seen a log of bickering, and most of it has 
     been internally within the Democratic Party, and I think 
     that's why they're turning off. And a lot of Democrats are 
     becoming disenchanted.
       Mr. Gregory: . . . What does the president need to address 
     to keep his own party in line? Should there be personnel 
     changes in the White House? What do you think the left is 
     going to demand?
       Mr. Moulitsas: Well, 2006 is going to be a base year. It's 
     going to be a base election.
       MR. Gregory: 2010, you mean.

  Mr. COBURN. Madam President, I wish to also quote from what I think 
is a brilliant letter by a Dr. Robert Geist from St. Paul, MN, that was 
written as a letter to the editor in the Wall Street Journal today. The 
title of his letter to the editor is, ``The First Cost Controller Will 
Be Your Own Doctor.'' It is something I have been talking about since 
we started this. The last thing we want to do in health care in America 
is to make it where the doctor is not a 100-percent advocate for the 
patient's best interest.
  He quotes very directly the transfer. He said a previous article 
written:

       . . . doesn't emphasize a potential stealth cost-control 
     aspect proposed in the bill. It will start pilot programs 
     that would transfer the gatekeeper role to doctors at the 
     bedside, a role currently held by ``payers'' (HMOs and 
     government-agency insurers, including Medicare and Medicaid).
       The transfer will be via capitation fee payments, making 
     clinics ``responsible'' for the cost of care of ``insured 
     lives'' for one year.

[[Page 32955]]

     . . . The illusion of many pundits and policy makers is that 
     mini provider gatekeepers can control costs after the very 
     powerful payer gatekeepers--

  That is, Medicare, Medicaid, and the large insurance companies--

     have failed for decades. The problem for patients is the 
     dilemma of all managed-care gatekeepers: cost, quality, 
     access; pick any two. It is not pleasant to think that one's 
     gatekeeper doctor will have to decide whether to order 
     surgery for your painful [worn out] hip or only to increase 
     the dose of--

  Anti-inflammatories because they are worried about costs.
  That is the key point. We are going to now separate physicians in 
this country for doing what is best for the patient to meet the demands 
of the government.
  Mr. ENSIGN. If the Senator will yield.
  Mr. COBURN. I will be happy to yield.
  Mr. ENSIGN. As a practicing physician, isn't this what the Senator 
saw in his practice with HMOs?
  Mr. COBURN. That is exactly why I am not a member of any HMOs.
  Mr. ENSIGN. Because we have kind of an insurance center system today, 
to a large degree, and now we are going to make that worse. Instead of 
going more toward a patient center, we are going to go from an 
insurance center to a government center to where these government 
bureaucrats now start being in control of eventually what kind of care 
you are going to get, what is paid for, and all that. We need to put 
the doctor and the patient back at the center of our health care 
system.
  Mr. COBURN. Let me finish this for a minute, if I might. Here is the 
summarizing paragraph:

       The economic reality is that no rationing of care supply 
     will ever control costs, when the problem is demand inflation 
     driven by popular insurance tax subsidies too sacred to 
     repeal. Consider that when federal fiscal ``necessity'' 
     overwhelms empty slogans,--

  Our empty slogans--

     scores of new bureaucracies created in [this bill] would be 
     able to implement Draconian rationing in collusion with 
     subservient insurance and ``provider'' corporations. The high 
     costs, as well as the rationing powers included in the more 
     than 2,000 pages of the ObamaCare Senate legislation are very 
     real.

  Which is the point I have been making all along. I am going to spend 
30 minutes tomorrow talking about the rationing aspects of what we are 
about to do as we pass this bill.
  Mr. BURR. If I can comment to my good friend, who started on a quest 
with me several years ago to try to put together a health care reform 
bill, I might say it was the first one introduced in the Congress in 
May of this year on comprehensive health care reform--not that it is 
better than anybody else's, but I can honestly say today it was true 
reform. I think that is what Dr. Coburn is trying to say.
  In this bill, it lacks reform. What do I mean by that? Their reform 
is to set up an advisory panel that if we exceed the costs we have 
designated for health care, they are going to cut the scope of coverage 
or the reimbursement. So either the array of coverage for a senior or 
for an American is ``skinnied down'' or we cut the reimbursement to the 
doctor or the hospital, and they call that reform.
  What Dr. Coburn and I found out, as many other Members have, is if 
you look at the successful companies across this country that have held 
down their health care costs through doing real reform--paying for 
prevention and wellness in work, changing the lifestyles of the 
employees--we saw companies that, for 4 years, had a 45-percent 
increase in their health care. Where is any of that in this bill? Out 
of 2,700-plus pages, there is no attempt to do that. There is no 
attempt to try to affect the lifestyles through supporting chronic 
disease management, prevention, and wellness, but we set up a lot of 
independent advisory boards.
  As a matter of fact, they were so scared that in the managers' 
amendment, it is no longer called the Medicare independent advisory 
board. It is called the independent advisory board. So the word 
``Medicare'' was dropped, not to signify that they are going to cut 
Medicare, but that is exactly what CBO and CMS have said. These will 
kick in. The question is, Are they sustainable or will Congress 
legislatively override their authority to cut the spending?
  Mr. ENSIGN. If my friend will yield, there is one part--actually one 
of the best parts in this bill--but there are so many other bad parts 
of this bill and the Senator from North Carolina mentioned them, and we 
have talked about a lot of them. The one place they actually have 
improved our health care system is the part that allows people to have 
larger discounts for healthier behaviors. Safeway was the model for 
this. They have done the most work on this in the last 4 years. Today, 
they can discount up to 20 percent of their health care premiums for 
people who engage in healthier behaviors--for not smoking, for being 
the proper body weight compared to their height, doing things such as 
that. If they are a nonsmoker, they get a lower premium, and if they 
even quit smoking, Safeway pays for the cessation products. To be fair, 
that is in the bill. Senator Carper and I got that in the Finance 
Committee. We were able to get that amendment drafted.
  The problem is, that is a tiny part of this bill. That should be a 
major focus of the bill. We should be able to buy insurance across 
State lines. Many of us have supported that--small business health 
plans, where small businesses can join together and take advantage of 
purchasing power. We all, on this side, almost everybody on this side 
of the aisle agrees with medical liability reform. The Congressional 
Budget Office said that would save $100 billion.
  The bottom line is, what we have been focused on--and I appreciate 
the efforts Senator Burr and Senator Coburn made in their bill last 
year--is trying to address the No. 1 problem we have in health care in 
the United States, which is costs. This bill does not address costs.
  As a matter of fact, you said it in your opening remarks. Total 
health care costs actually, according to President Obama's CMS, go up 
$234 billion if nothing is done. If nothing is done, we actually save 
money on total health care spending. But with this bill, it actually 
goes up by $234 billion.
  Mr. COBURN. What we also know from the Congressional Budget Office is 
that between 9 and 10 million people who today have insurance through 
their employer will actually lose it. They are going to lose their 
insurance. That may be good or bad for them. But if you look at the 
incentives, the subsidy for people who do not get insurance through 
their employer, if you make $42,000 a year, today with your health 
insurance through your employer you get a benefit of about $5,749 from 
the tax system. But under this bill, you will be eligible for $12,500 
worth of subsidy.
  What do you think an employer is going to do? They are going to look 
at their employees and they are going to say: I have to pay this 
penalty if I don't offer this, but it is a significantly smaller amount 
than what I am paying today. Therefore, I am going to make a decision 
to no longer offer health insurance, give my employees a small raise 
because the government is going to come in with $12,500 worth of 
subsidies to put them in a ``private'' plan inside the parameters of 
what is in the exchange. How many people do you think it is going to 
shift?
  What we are going to get is adverse selection. So the individual--
let's say I am working and I am making $42,000 a year and my employer 
decides to do that and let's say I am 35 years old and I know available 
to me is $12,500. Even though my earnings may go up, I am still 2\1/2\ 
times better off.
  I also know I will have to pay $3,000 or $4,000 of my own money to 
get that benefit. I will not cover myself because I know I can cover my 
little incidentals. If I get sick, they have to cover me in the 
exchange.
  So we are going to see adverse selection in the insurance market, 
people who are between 40 and 64 who are sick are going to pay far more 
for their health insurance and people who are sick who are younger than 
40 are going to pay far more for their health insurance and everybody 
who is healthy under 40 is going to say: This is an economic bonanza 
for me. I am not going to buy insurance.
  Mr. ENSIGN. I see our friend from South Carolina has joined us. He 
has

[[Page 32956]]

spoken eloquently about some of the sweetheart deals that have been 
made in this plan to ``buy'' votes. Could the Senator from South 
Carolina address those?
  Mr. GRAHAM. I don't know if you could call it a sweetheart deal more 
than it is just repugnant. The campaign in 2008 was about change we 
could believe in. I do believe one of the reasons President Obama won 
is because he convinced young people in this country that if he got to 
be President, this country was going to change for the better; we were 
going to do things differently, and that resonated with people.
  Quite frankly, when we were in charge, as Republicans, we let people 
down. We let things get out of control on our watch. Some of our people 
wound up going to jail. The Iraq war was not popular. So you had this 
new, young, exciting, articulate figure come along and promise a new 
way of doing business. That is what hurts so much about this bill. The 
special deals the Senator just mentioned remind us all why Congress is 
in such low standing.
  The 60th vote--how did they get it? Did they negotiate the 60th vote 
on C-SPAN in a transparent manner promised in the campaign that we 
would have negotiations on C-SPAN so that you, the American people, 
could watch what was being given and what was being taken and there 
will be no more backroom deals?
  Here is what happened. They took one Senator who was the key guy and 
they put him in a room. We had no access to that room and no Democrat 
did either. After it is all said and done, here is what resulted from 
those negotiations that were not on C-SPAN.
  Nebraska is going to be the only State in the Union, ladies and 
gentlemen, that new Medicaid enrollees will be covered by the Federal 
Government. Every other State in the Union, when you sign up a new 
person on Medicaid, because you are expanding the number of people 
eligible for Medicaid, your State is going to have to make a matching 
contribution.
  In my State of South Carolina, with 12 percent unemployment, there is 
going to be one-half million more people eligible for Medicaid under 
this bill than exists today. It will cost my State of South Carolina $1 
billion. But if you live in Nebraska, it doesn't cost you a damn dime 
because that is what it took to get a vote.
  If that is change we can believe in, count me out. If that is OK with 
the American people, I can tell you our best days are behind us. The 
insurance companies in Nebraska got a deal that no other insurance 
company in the Nation got. Physician-owned hospitals in Nebraska got a 
deal that nobody else got. Louisiana got $300 million to help with 
their Medicaid problems that nobody else got.
  If you want your country to be run in a more businesslike fashion, 
then you need to speak up. You have a chance between now and sometime 
in January, when this goes back to the House, to let your voice be 
heard.
  To my good friend from Nevada, the special deals in this bill are not 
special. They are the same old crap we have been putting up with for 
decades up here and that people thought was going to come to an end. It 
is going to hurt your children's ability to have half of what you have 
because they cannot make it because you are about to pass on a bill to 
them they cannot pay.
  What I hope will happen, I say to my good friend, the Senator from 
Nevada, is that the people will take their government back. If you 
think this deal from Nebraska is unacceptable, speak up and speak out 
and let the House Members know you want it changed.
  Mr. BURR. I thank our colleague from South Carolina. I know we are 
about to run out of time, but I wanted to go back to the Chief Actuary 
at Medicare because I think the way they analyzed the bill is 
absolutely essential for the American people to understand what is in 
it.
  The Chief Actuary, the President's Actuary, said:

       The Reid bill funds $930 billion in new spending by relying 
     on Medicare payment cuts which are unlikely to be sustainable 
     on a permanent basis.

  It gets to what Dr. Coburn said. By design, maybe this could work, 
but there is not a will because there is not reform. We have spent a 
lot of money, and at the end of the day, it looks as if the only thing 
we have done is tried to address waste, fraud, and abuse. For $2.3 
trillion, it seems as if you could bring more bacon to the table. It 
seems as if there would be a little more meat.
  It seems as if there would be some substance there we could look at 
and say: Look at the improvements our health care system makes.
  I know Dr. Coburn has said many times: If we do this wrong, what we 
do is we chase innovation out of this country, out of our system, the 
breakthroughs that go from maintenance to cure, the research on a bench 
that finds us new ways to address diabetes where amputation and 
blindness are not in somebody's future. If we go backward, if we chase 
that innovation out, we lock ourselves into not only the most costly 
health care but health care that achieves the least amount of quality 
for future generations.
  Mr. ENSIGN. I wish to ask Senator Coburn to address, in the last 
couple of minutes here--because he has spoken so eloquently about debt 
and the Congressional Budget Office saying this helps the deficit by 
some $100 billion--how the taxes go into effect right away and that the 
spending doesn't go into effect, and how that kind of smoke and mirrors 
happens all the time around here; how they try to hide various 
expenses, and what this is going to do to our debt.
  Mr. COBURN. Well, the disappointing thing--and I have worked on this 
for 5 years, since I have been here--is we are not honest with the 
American people about how we account for things, and this bill is 
another example of that. Let me give you the quantifications.
  If you read the CBO report on this bill, they talk about it is highly 
unlikely we will ever actually make the Medicare cuts, because they 
have never seen it done, and every time we have said it in the past, we 
haven't done it, like the sustainable growth rate formula in the 
Balanced Budget Act of 1997. So if you match up revenues and expenses, 
what you see is a $1 trillion tax increase, a $1 trillion cut in 
Medicare, and an increasing cost to the economy.
  But because there is not the sustainable growth rate--the doctor fix 
in the bill--that is $247 billion not accounted for, and that is if you 
keep physician wages frozen over the next 10 years. That is $247 
billion, probably closer to $300 billion. So that is $300 billion. The 
fact is we know the taxes that are going to be collected, people are 
going to pull down the cost, which is one of their hopes, and they are 
going to pay for it out of their pocket.
  So we are going to see that insurance plans not reach the Cadillac 
level, and we are counting on revenues from that in terms of billions 
and billions and billions of dollars. But what they will do is change 
the deductibles--and that is a hidden tax. Because if your deductible 
goes up to keep your insurance from going too high, your tax goes up in 
actual expenditures. So your ability to invest and create additional 
jobs--in other words, it cascades. The honest accounting for this is 
that there is no way this saves any money. It will cost money.
  The final point I will make is they won't put forward the cuts in 
Medicare that they are claiming in this bill. Because they know if they 
truly do put forth the cuts, and patients feel it, they won't be back 
here. So it won't happen.
  I will go back to what Senator Burr started this out with. If you are 
going to start tomorrow and fix health care, what would you do? You 
would attack costs. Why are things so costly? One is because there is 
no transparency in markets. There is no real connectedness to your 
pocket. No. 3, there is no incentive for prevention of chronic disease 
or the management of it. In other words, we don't pay people to have 
less expensive outcomes. We won't incentivize better care in that way. 
We won't incentivize prevention.
  We have done a lot of this on Medicare--and I will talk about it 
tomorrow--but they have three different

[[Page 32957]]

agencies within this bill that are going to ration care. They are going 
to make the decisions for you, and not just on Medicare and Medicaid. 
Everybody needs to understand that. It doesn't just apply to Medicare 
and Medicaid, it applies to your choice of your private insurance. The 
government is going to ration your care.
  We know that is true because they wouldn't allow an amendment to 
prohibit rationing. They all voted against the amendments in committees 
when we offered amendments to limit rationing. So we know the intention 
is to ration care. If that is how we are going to control costs, then 
Bernie Sanders is right--go to a single-payer, government-run system. 
Bernie Sanders' system is far better than this one--far better than 
this one--if that is what we are going to do. If we are going to ration 
care, let everybody know it upfront. Let's be absolutely honest about 
it.
  If you are 75 years of age and need a hip replacement but the quality 
of your life is not all that great, we are going to say you can't have 
it. That is what we are going to do, because that is exactly what they 
do in England. They have the National Institute of Comparative 
Effectiveness which makes an evaluation of what your worth is. And no 
matter what your history, no matter what your family situation, no 
matter your income, you can't have it.
  Canada is getting around that, because they have said you get the 
right to buy what you want. Their Supreme Court ruled on that 2\1/2\ 
years ago. So we are seeing a two-tiered system developing in Canada, 
which ultimately will happen in this country--worse than what we have 
today.
  Mr. ENSIGN. If the Senator will yield, though, if America does this 
with our health care system, where will the Canadians come for their 
health care when they need it? When they get it rationed up there, they 
usually come to the United States.
  Mr. COBURN. They will go to Thailand or India.
  Mr. ENSIGN. But where will Americans go?
  Mr. COBURN. I thank the Senator for holding this colloquy, and I will 
make one final point before I stop.
  I don't doubt the motivation of our colleagues on the other side of 
the aisle. They want us to fix this problem--the problem in health 
care. But the problem is cost. If you don't fix cost, and you expand 
the same broken system, you haven't fixed anything. You have added to 
the cost.
  Mr. BURR. I thank the good doctor, and I thank the Presiding Officer, 
and I yield the floor.
  The PRESIDING OFFICER (Mr. Merkley). The Senator from New Jersey is 
recognized.
  Mr. MENENDEZ. Mr. President, I rise to speak to the great debate we 
are having on historic health care reform, and I am reminded of the 
words of a great Republican, President Abraham Lincoln. He said:

       We cannot escape history. The fiery trial through which we 
     pass will light us down in honor or dishonor of the latest 
     generation. The occasion is piled high with difficulty and we 
     must rise with the occasion.

  That is what Abraham Lincoln said. It is time to rise to the occasion 
because our friends on the other side of the aisle have chosen to sit 
on their hands and do nothing. They have no plan. They have chosen to 
delay and obfuscate.
  If you look back in history, during the great debates on Social 
Security in 1935 and Medicare in 1965, our friends across the aisle 
were on the wrong side of history. But in the end, there was a minority 
that chose to stand up for historic social legislation and vote their 
conscience. They were not driven by the far rightwing of their party or 
by radio talk show hosts who demand ideological purity and see any 
attempt to support health care reform as an abandonment of principle.
  Each of us is rarely called to act on such significant legislation, 
and when we are, it is our solemn duty to put aside our idealogy--turn 
off Rush Limbaugh--and leave politics in the cloakroom. Our vote on 
this ground-breaking legislation--comparable to Social Security and 
Medicare--will be one of the most significant votes in American 
history. It should not be driven by the hope of failure that the other 
side prays for, rather by the will to succeed for the American people. 
This Congress will be remembered for this vote for generations to come, 
and our friends across the aisle will once again be on the wrong side 
of history.
  We have heard the same tired arguments over and over. We heard those 
arguments in 1935 against Social Security. We heard them again in 1965 
against Medicare--the same arguments we hear today. History has a way 
of repeating itself. If past is prologue, historic health care reform 
legislation will be signed into law despite the naysayers, the 
fearmongers, the panderers to those who see any attempt at compromise 
as defeat.
  To our friends on the other side, this is no longer about 
legislating, it is simply about obstructing. It is no longer about 
doing what is right for the American people but about stopping us from 
doing anything. It is not about finding common ground but drawing lines 
in the sand.
  My friends on the other side have set up an army of straw men, as 
they did on Social Security and Medicare, manipulating the facts to 
create the illusion of refuting the false claims they created in an 
attempt to score political points.
  They stand up the socialist straw man, call the bill a government 
takeover of health care, and make Americans fear it. Well, we say: 
Let's make sure the Bernie Madoffs of the world, and people like him, 
are not selling health insurance.
  They wave the flag, stand up the un-American straw man, saying the 
bill is against old-fashioned American values and denounce it. We say: 
Don't you dare question our patriotism. Do not dare question our 
commitment to doing what is right for the American people.
  They stand up the death panel straw man, claiming the legislation 
would kill grandma, and denounce it as inhumane. We say: Stop the 
outrageous misinformation and tell the truth to the American people.
  They stand up the taxing straw man, and say health care reform will 
increase taxes. We say: We are making health care entities, such as 
insurance companies, pay their fair share.
  They set up the spending straw man, and say the bill will indebt the 
next generation, despite Congressional Budget Office estimates to the 
contrary. We say: You can't pick and choose when to believe the 
Congressional Budget Office and stand by their numbers only when it is 
convenient to your cause.
  For instance, my friend Senator Gregg, the ranking member on the 
Budget Committee, touts CBO numbers even on his specific bill, when 
they benefit his arguments, for example, on malpractice provisions. But 
now my friends on the other side conveniently dismiss the Congressional 
Budget Office numbers showing our health care plan reduces the deficit. 
So you can't have it both ways.
  They bring along their partisan straw man, accusing us of drafting a 
bill or having votes in the middle of the night. We say: How quickly 
you forget the 4 months that we waited for Republicans in the 
bipartisan Gang of 6, three Democratic Members, three Republican 
Members, working, supposedly, to achieve a bipartisan effort in health 
care reform. Four months. Four months we waited for them to work with 
us in a constructive way, and then they all walked away. So don't come 
back now and say you had no input in the process when you chose that 
course.
  And, by the way, these votes that take place at the time they take 
place are because the Republicans insist on stopping the process and 
delaying it and drawing it out. So under the procedures, once we start 
the process to finish that delay, it ends up at certain hours--30 hours 
each time from the moment we file a motion to say that is enough of the 
delay, let us move forward. Whenever those 30 hours end, that is when 
we have to have the vote. But they could consent to have that vote in 
the fullness of the day and light. But no, they want to have the

[[Page 32958]]

vote as late as possible, hoping that 60 Members who want to see 
progress on this reform don't come to this Chamber and, therefore, 
cannot stop the filibuster. They want failure, and then they clamor 
about the time these votes take place.
  Straw man after straw man. They have done nothing but block this 
legislation, as they have throughout the year on other legislation. 
They will do anything, say anything to delay, deny, and defeat health 
care reform.
  They are on the wrong side of history now, as they were in 1935 and 
1965. But the difference between 1935 and Social Security and 1965 and 
Medicare and today is that when the debates ended in 1935 and 1965, 
when the legislation was weighed on its merits, there were those few 
Republicans who voted their conscience, those who did not march in 
lockstep to the demands of rightwing talk show hosts or in fear of tea 
party anarchists.
  In 1935 and 1965, there were a few on the other side, a few who voted 
for Social Security and Medicare because they knew it was right for 
America. But in 2009 it appears there will be no votes for health care 
reform--not one, not a single vote from the other side of the aisle.
  The ideological differences were as intense then as they are now but 
pure obstinate ideology did not prevail then as it will in this Chamber 
when we vote. Before Social Security was debated, President Roosevelt 
laid out the changes in society and the reasons why we needed Social 
Security legislation before the Congress. He said then:

       Security was attained in the early days through the 
     interdependence of members of families upon each other and of 
     the families within a small community upon each other. . . .
       The complexities of great communities and of organized 
     industry make less real the simple means of security. 
     Therefore, we are compelled to employ the active interests of 
     the nation as a whole, through government, in order to 
     encourage a greater security for each individual who composes 
     it.

  That is what he said about Social Security. That is why we needed 
Social Security and why we realize today that without Social Security 
more than half of our seniors in this country would be living in 
poverty--more than half--if the voices then in opposition had 
succeeded.
  Then the debate began. There is no mention of death panels but there 
were those Republicans who raised similar straw men to the voices we 
hear today. A member of the New York delegation, a Republican, Daniel 
Reed said:

       The lash of the dictator will be felt, and 25 million 
     Americans will for the first time submit themselves to a 
     fingerprint test.

  Another said:

       The bill . . . invites the entrance into the political 
     field of a power so vast, so powerful as to threaten the 
     integrity of our institutions and pull the pillars of the 
     temple down upon the heads of our descendants.

  John Taber, another member of the New York delegation, a Republican, 
raised the antibusiness straw man, saying:

       Never in the history of the world has any measure been 
     brought here so insidiously designed as to prevent business 
     recovery, to enslave workers.

  In this Chamber, in the Senate, Senator Daniel Hastings of Delaware, 
a Republican, raised the death-of-a-nation straw man, saying that 
Social Security would ``end the progress of a great country.''
  In this debate we have seen the same army of straw men standing 
against us. They have claimed that health care reform is a government 
takeover that will threaten the integrity of our institutions, when in 
fact we create an exchange of private insurance companies that people 
will be able to pursue.
  They say it will ``pull down the pillars of the temple on our 
descendants'' and leave them in debt, that it will drive private health 
insurers out of business and put a bureaucrat between doctors and 
patients.
  We already have bureaucrats between doctors and patients. They are 
health insurance company bureaucrats between doctors and patients. The 
difference is when the debate ended on Social Security in 1935, when 
the shouts of socialism and un-Americanism had faded, a few, a minority 
on the other side, had the political courage to cross the line and vote 
yes.
  But there will not be a single vote from the Republicans in favor of 
this bill, not a single vote. Our colleagues on the other side want 
nothing more than to stop this bill, period, pure and simple. It is 
their intention to stand en bloc for insurance companies and against 
any health reform that would protect American families from losing 
everything if they get sick. Their plan is just to say no; and once 
again they will squarely be on the wrong side of history.
  When President Kennedy and later Lyndon Johnson fought for Medicare, 
those on the other side raised the same army of straw men they raised 
30 years earlier. They played the same game they are playing again now. 
Senator Curtis of Nebraska at that time voiced opposition in this 
Chamber saying, ``Medicare is not needed.'' He was a Republican Senator 
of the time, Mr. Curtis of Nebraska, who said:

       [Medicare] is not needed. It is socialism. It moves the 
     country in a direction which is not good for anyone, whether 
     they be young or old. It charts a course from which there 
     will be no turning back. It is not only socialism, it is 
     brazen socialism.

  In the other body, Congressman Hall of Missouri called it ``an ill-
conceived adventure in government medicine.''
  Those were the Republican voices of the past on Medicare. What senior 
in this country today--which one of our parents or grandparents--
believes those words of the past as they relate to their health care 
today? More straw men, more fear, more naysaying--all of it wrong then, 
all of it wrong now.
  They said bureaucrats would come between doctors and patients. They 
are wrong. That is why it is interesting to see that today the American 
Medical Association, the Nation's doctors--the people who take care of 
you when you are ill, the ones who follow your progress when you have, 
maybe, a debilitating disease or a lifetime health challenge, your 
doctor, the voice of your doctor, not any Members of the Senate, the 
voice of your doctor in support of this historic reform--said:

       This is a time of great opportunity for the American health 
     care system. We have the chance to substantially expand 
     health insurance coverage, implement insurance market reforms 
     that promote greater choice, affordability and security, 
     improve [this is the doctors speaking] the quality of the 
     care and help Americans live longer, healthier, happier and 
     more productive lives. To that end [the doctors of the nation 
     say] we urge all Senators to support passage of the Patient 
     Protection and Affordable Care Act as amended.
  This is the Nation's doctors. This is your doctor who is telling the 
Members of the Senate: Vote for it. They do not believe the line that 
bureaucrats are going to come between doctors and patients. They are 
wrong, those who are saying that.
  They called Medicare unpatriotic and un-American. They were wrong 
again. They said it would mean the rationing of health care. They were 
wrong. They made the same argument they have been making for 74 years, 
and they are still wrong.
  In 1965, the champion of my conservative friends, Ronald Reagan, 
issued a 19-minute-long LP, for those of us who still remember that, a 
long-playing vinyl recording at the time. It is past--gone. They are 
like antiques now. But it was entitled ``Ronald Reagan Speaks Out 
Against Socialized Medicine.''
  It featured an impassioned 2,000-word speech intended to get people 
to write to their Congressman against the idea of Medicare that was 
beginning to make its way through the Congress. That was 1965. It was 
referred to as Operation Coffee Cup, something of a precursor to 
today's tea parties. In his record message, Ronald Reagan said:

       One of the traditional methods of imposing socialism on 
     people has been by way of medicine. . . .

  Does it sound familiar, in the year 2009, in the debates we have 
heard here on the floor? When he became President, one of the pillars 
of his health policy was cutting benefits, in particular through 
increased cost sharing for Medicare and Medicaid recipients. He was 
wrong then, just as our conservative friends are wrong now.
  In the face of yet another landmark piece of legislation, is it 
possible there is not one of my friends on the other

[[Page 32959]]

side who does not in their heart believe we need to pass this 
legislation for the good of the American people, regardless of 
ideology? Is there not one of my friends on the other side who will 
vote yes to help Americans who have lost their jobs and their health 
care and stand to lose everything if they or a member of their family 
becomes ill?
  My friends, saying no to accessible, affordable health care for the 
American people is too big a price to pay for ideological purity. When 
I think of what this legislation will do, I cannot believe there will 
not be one vote on the other side to provide competition and affordable 
choices for every American, as this bill does; not one vote for greater 
accountability for health insurance companies; not a vote for more 
choice and competition for consumers, for programs that will rein in 
health costs and make policies more affordable.
  Is this bill perfect? No. But it is a great and historic foundation 
of reform. Yet there will not be one vote on the other side to improve 
access to quality care for children, as this bill provides for, and the 
most vulnerable among us, which the bill does. Not a single vote for 
tougher accountability policies, for health insurance companies that 
are included in this legislation? Not one vote to require insurers to 
spend more of the premium revenues on health care rather than on 
administrative costs, executive compensation, and boosting the bottom 
line? Not a vote to hold health insurers accountable for excessive rate 
increases? Not a single vote on the other side to immediately ban 
insurance companies from denying children--we hear a lot about the 
sanctity of life--coverage for a preexisting condition? Not one vote 
for expanding eligibility for tax credits for small businesses and 
starting the health insurance tax credit next year? That is why it is 
interesting to note that among the many supporters of this, the 
Business Roundtable, they are quoted as saying:

       The proposed legislation is a step towards our shared goal 
     of providing high quality, affordable health care for all 
     Americans.

  It is why the Small Business Majority says the managers' amendment, 
Senator Reid's amendment, ``includes new provisions essential for small 
business protection and survival.'' That is the voice of business.
  Not one vote for a bill that promotes competition for insurers and 
choice for workers? Or to test alternatives to civil tort legislation 
that emphasize patient safety, disclosure of health care errors, and 
resolutions of disputes? Not one vote.
  Not one vote for people in my home State of New Jersey and every 
State who will see direct and immediate benefits from this legislation? 
Not a vote for every uninsured Jerseyan who has a preexisting condition 
and has been unable to find affordable health insurance in the 
marketplace? The health of our families is not a commodity. It is not a 
privilege for the wealthy. It is something everyone should be able to 
be protected from without going broke.
  Under this legislation, 1.3 million seniors in my home State will be 
eligible for free preventive care for recommended services. Seniors 
will also be eligible for free annual wellness visits to their doctors, 
and will be provided with a personalized prevention plan so they can 
stay healthy.
  When this legislation is signed, we will have lived up to our promise 
to fill the doughnut hole, that gap in coverage under Medicare Part D, 
to provide affordable prescription drugs to over 227,000 seniors in New 
Jersey and millions across the country so they will no longer have to 
choose between paying their bills and taking the medication.
  When this legislation is signed, over 850,000 New Jerseyans will 
qualify for tax credits to help them pay for health insurance, easing 
the burdens, premiums, deductibles, and copayments. It will make tax 
credits for up to 50 percent of health care premiums available to over 
100,000 small businesses in New Jersey. It will also put an end to the 
hidden tax that is passed along to everyone in my State through 
increased premiums and costs to pay for the over $1 billion spent on 
uncompensated care in New Jersey.
  This legislation includes a health insurance exchange that would 
provide portability, security, and choice for 1.3 million New Jersey 
residents who presently do not have any health insurance whatsoever. It 
will increase the number of doctors, nurses, and dentists for the 
150,000 New Jerseyans, 2 percent of the population who live in areas 
where they do not have access to primary care because of a shortage of 
health care providers in their communities, yet there will not be one 
single vote for this legislation on the other side, not a single vote 
for any of these health reforms to help hard-working families in my 
State and in States across the country.
  This is the politics of no, pure and simple. I suppose it is nice to 
say no to health care reform when you have the full protection of 
health care yourself. But it is wrong to say you are unwilling to 
afford the same protections to others. It is nice to say no to health 
care reform when you and your family will not be denied coverage 
because of the privileged position you hold but wrong to let even one 
mother, one father hear that their child has been denied the medical 
treatment they desperately need.
  I say to my friends, how dare you stand in unison on the other side 
of the aisle and deny to others that which you so fully enjoy 
yourselves. How can you deny to others that which you so fully enjoy 
yourselves. It is inconceivable to me that when all is said and done, 
when our differences have been aired and debate has ended, that not one 
of my colleagues on the other side will see the historic nature of this 
legislation. We can be proud of this legislation. I know when the dust 
settles and the provisions of the bill become clear, America will be 
proud of it as well.
  This landmark reform legislation includes State-based insurance 
exchanges, creating a fair, open, competitive marketplace for 
affordable coverage. It includes an amendment I proposed for long 
overdue consumer protections for emergency services. When you are 
getting sent to a hospital, you are not thinking about calling your 
company and saying: Is this the right hospital? Am I going to be 
covered without regard to prior authorization?
  It requires insurance plans to provide behavioral health treatments, 
such as those for children who are autistic, as part of the minimum 
benefits standard. It encourages investments in new therapy to prevent, 
diagnose, and treat acute and chronic disease with a tax credit for 
innovative biotechnology research. It ensures that minor children 
qualify as exchange-eligible and provides for the availability of 
child-only health insurance coverage in the exchanges. It stops 
insurance companies from denying coverage for preexisting conditions, 
health status, or gender, and it ends the medical benefits shell game 
that insurers have played with people's lives.
  The bottom line is this legislation helps New Jersey and America. It 
is fair, balanced, and fixes a badly broken system. It is truly a 
historic piece of legislation and will be remembered as such. Yet every 
one of my colleagues on the other side will vote no. They will stand 
against all of it, all I have talked about, firmly, once again, on the 
wrong side of history.
  Let me conclude by saying, as I have said before, and I will say 
again, history calls on us to stand up on rare occasions for what is 
fair and just and right for the American people. This is one of those 
occasions. This is a time to look into your heart, a time to see beyond 
your own political interests, your own hard ideology, and look at the 
lives of millions of Americans. Think about the millions of families on 
Main Street, in every community, where a child wakes up in the middle 
of the night to a parent who cannot afford to get them the basic care 
they need. Ask yourself: What is the right thing to do?
  This is a time to do what is right for America. It requires more than 
parliamentary maneuvers to slow the process. It requires more than 
shrill voices raised under the banner of free market values at the 
expense of fundamental human values. It requires doing what is right 
for the millions of American families who have lost their jobs

[[Page 32960]]

and their health care, those who have suffered from the economic 
policies of the last 8 years and now find themselves hurting. This is a 
time to remember them, a time to remember every mother who cries 
herself to sleep at night because she lost her job, lost her health 
care for herself and her infant and could lose everything she struggled 
for in her life, if she gets sick.
  I say again to my friends, how dare you deny to her the protections 
that you so fully enjoy yourself. How dare you turn this into a 
parliamentary game of delay, deny, and defeat. Those who have 
continuously said no to any attempt at health care reform and yes to 
the needs of the insurance industry believe that the business of 
government is business. But for all of us who know the business of 
government, what it really is, it is about people. It is about those 
who send us here. It is their lives, their hopes, their dreams for a 
better life for themselves and their families. This is an opportunity 
to stand up for them. This is an opportunity to take care of their 
health care. This is an opportunity to show whose side you are on.
  Are you on the side of those families or are you on the side of the 
special interests that would have you vote no, or the ideological 
interests that would have you vote no against these families? This is 
historic legislation. I am afraid our friends on the other side will 
once again, as they did in Social Security and Medicare, find 
themselves on the wrong side of history.
  I intend to be on the right side of history and to vote yes on this 
legislation.
  I yield the floor.
  Mr. JOHNSON. Mr. President, I wish today to recognize the progress 
made on health care reform, as well as stress the fact that we must 
press forward. Americans face out-of-control health care costs, great 
inequalities in access to care, eroding benefits, and the ever-
increasing threat of losing their health insurance. While it has not 
been an easy task to reach a consensus, we find ourselves very close to 
fixing our health care system and extending access to health insurance 
to over 31 million Americans.
  I have heard from countless South Dakotans whose stories illustrate 
the urgent need for reform. Just as the diseases and health care 
emergencies they face cannot be postponed, it is imperative we forge 
ahead and deliver reforms that will improve their health and security.
  I would like to share the story of Susan from Rapid City, SD, a 57-
year-old woman who has nearly depleted her savings and plans to sell 
her home in order to pay her bills and medical expenses. Her husband 
passed away several years ago and she now survives on his modest 
pension. After exhausting COBRA health insurance, she bought the only 
private health insurance policy she could afford. She was forced to 
accept several riders for her preexisting conditions, arthritis and hay 
fever, so her insurance ``won't cover the problems that will soon need 
attention.'' She also has to pay out-of-pocket for most her 
preventative screenings and primary care because she has not reached 
her $5,000 deductible. She writes, ``I feel I am paying $250 a month 
for unreliable health insurance.'' Until she reaches Medicare age or 
can qualify for Medicaid, her only option is to sell down her assets to 
pay the bills.
  Like millions of Americans, Susan is vulnerable in the non-group 
health insurance market, where coverage is often expensive, inadequate 
and certainly not guaranteed. ``Without the security of group 
coverage,'' she notes, ``I am very vulnerable and am one illness away 
from a catastrophe.'' Several provisions in the Patient Protection and 
Affordable Care Act will help Americans like Susan gain access to 
quality, affordable health insurance.
  Under the Senate reform bill, all health insurers will be prohibited 
from using preexisting conditions to deny health care and it will be 
illegal for them to drop coverage when illness strikes. Health 
insurance exchanges will create an accessible marketplace for Americans 
to shop for the best plan to meet their needs. Health insurers will 
offer national plans to all Americans under the supervision of the 
Office of Personnel Management, the same entity that oversees health 
plans for Members of Congress. Tax credits will be available to make 
insurance more affordable for those who need assistance, and the choice 
of doctor will be protected. These health insurance market reforms 
demand greater accountability from insurance companies while creating 
more choice and competition for consumers.
  Despite a commitment by some to kill reform and defend the status 
quo, I am confident the strong consensus on the urgent need for reform 
will prevail. The cost of inaction is too great.
  Mr. LEVIN. Mr. President, the health insurance provider annual fee in 
the so-called merged Senate health care reform bill did not distinguish 
between nonprofits and for-profit insurance companies in this country, 
although our current tax law properly does make the distinction.
  I urged that the managers' package modify the fee to continue to 
recognize the distinction.
  Imposing the annual fee on true non-profits, particularly those with 
high pay-out rates to beneficiaries, would have pushed many of those 
true non-profits into deep financial difficulties and would have caused 
significant hardships on the families who rely on their services.
  Some nonprofit insurers have not maximized the amount they pay out in 
medical expenses to beneficiaries. That is why I urged the managers to 
include in the managers' package a provision exempting from the tax 
only those nonprofits with very high payout rates. Those good 
performers are committed to their policyholders rather than to profits 
for stockholders, which is the goal of the for-profits. Those good 
performing nonprofits are unable, as a result, to absorb the fees.
  The managers' amendment specifies two ways for nonprofits to be 
exempt from the fee.
  The first way for a nonprofit insurer to be exempt from the fee: one, 
it can not refuse to insure anyone in the State and is the State's 
insurer of last resort; two, its premium prices are regulated by its 
State insurance regulator; and three, it must pay out in medical 
expenses 100 percent or more of its premium revenues in the individual 
market.
  The second way for a nonprofit to be exempt: the nonprofit insurer 
must pay out a very high percentage of its premium dollars--at least 90 
percent--in medical expenses in each of the three major market 
segments: individual market, small group market, and the large group 
market; and it also must have an even higher overall payout rate of at 
least 92 percent. A nonprofit that compresses its margins that far 
beyond its peers for the benefit of its policyholders also warrants the 
exemption.
  These exemptions continue the distinction that our tax law has 
recognized--that true nonprofit insurance providers should not be 
treated the same as their for-profit counterparts.
  Mr. LEAHY. Mr. President, after months of arduous work, the Senate 
will finally take the first significant step toward bringing needed 
reforms to health care in this Nation. Opponents of reform have wasted 
much of the public's time by provoking arguments over their distortions 
about what health reform means. Opponents have tried to demonize the 
plan, and have claimed it will never work. We have overcome weeks of 
delay tactics employed by the minority--inexplicably, the most recent 
delay due to a filibuster against a bill to provide funding for our 
troops. These are the tactics of obstruction, and further demonstrate 
Republicans' efforts to maintain the status quo.
  Is this the exact bill that any one of us would have written? 
Probably not. I remain disappointed that the managers' amendment before 
us today strips the bill of a public insurance option to compete with 
private plans and does not include a provision I have sponsored to 
repeal the antitrust exemption for health insurers and medical 
malpractice insurers. I believe both of these provisions would go far 
in providing fair competition into the health insurance market.

[[Page 32961]]

  But in looking at this bill as a whole, I believe it stands by the 
core principles I sought at the beginning of this debate. It gives 
Americans affordable access to health care coverage, it reduces costs 
for families, businesses and government, and it protects consumers' 
ability to choose doctors, hospitals and insurance plans.
  The managers' amendment introduced by the majority leader 
incorporates many important changes to the underlying legislation that 
will improve the bill. It includes several provisions that I have long 
supported and promoted.
  Vermont has always been a national leader in expanding access to 
health insurance. In coordinating care, offering comprehensive coverage 
to children, and developing a system of electronic health records, 
Vermont has been at the forefront of reform. It is no surprise that for 
the third year in a row Vermont has been ranked the healthiest State in 
the Nation.
  Unfortunately, a provision included in the underlying bill to expand 
Medicaid coverage nationwide threatened to penalize Vermont by 
excluding the State from increased Federal funding, solely because 
Vermont acted early to do the right thing. We can all share the goal of 
increasing access to essential medical services by expanding Medicaid 
coverage nationwide, but we should not penalize States such as Vermont, 
which demonstrated the initiative to expand its Medicaid Program early.
  Senator Reid's amendment, however, remedies the anomaly in the 
underlying bill, and will allow Vermont to access additional Federal 
funding when the Medicaid expansion goes into effect. I thank Senators 
Reid and Baucus for working with me to ensure that Vermont's efforts to 
expand coverage to low income individuals is not set back by inequities 
in the underlying legislation.
  The managers' amendment also incorporates a vital antifraud amendment 
Senator Kaufman and I, as well as Senators Specter, Kohl, Schumer, and 
Klobuchar, introduced, derived from the Health Care Fraud Enforcement 
Act which we introduced earlier this fall.
  This antifraud initiative builds on the impressive steps the 
administration has already taken to step up health care fraud 
prevention and enforcement, and on the real progress represented by the 
antifraud provisions adopted by the Finance and HELP Committees and 
incorporated into the leader's health care reform bill. I was glad to 
contribute to those efforts, and I am glad we are now going even 
further.
  The Kaufman-Leahy provision will provide prosecutors with needed 
tools for the effective investigation, prosecution, and punishment of 
health care fraud. By making modest but important changes to the law, 
it ensures that those who drain our health care system of billions of 
dollars each year, driving up costs and risking patient lives, will go 
to jail, and that their fraudulent gains will be returned to American 
taxpayers and health care beneficiaries.
  For more than three decades, I have fought in Congress to combat 
fraud and protect taxpayer dollars. This spring, I introduced with 
Senator Grassley and Senator Kaufman the Fraud Enforcement and Recovery 
Act, the most significant antifraud legislation in more than a decade. 
When that legislation was enacted, it provided law enforcement with new 
tools to detect and prosecute financial and mortgage fraud. Now, as 
health care reform moves through the Senate, I am glad we are taking 
steps to do all we can to tackle the fraud that has contributed greatly 
to the skyrocketing cost of health care.
  The scale of health care fraud in America today is staggering. 
According to even the most conservative estimates, at least 3 percent 
of the funds spent on health care are lost to fraud--more than $60 
billion a year. In the Medicare Program alone, the General 
Accountability Office estimates that more than $10 billon was lost to 
fraud just last year. While Medicare and Medicaid fraud is significant, 
it is important to remember that health care fraud does not occur 
solely in the public sector. Private health insurers also see billions 
of dollars lost to fraud. That fraud is often harder for the government 
to track. Private companies have less incentive to report it, and in 
some cases, are responsible for the fraudulent practices themselves. 
Reining in private sector fraud must be a part of any comprehensive 
health care reform.
  The Kaufman-Leahy provision makes a number of straightforward, 
important improvements to existing statutes to strengthen prosecutors' 
ability to combat health care fraud. The bill would increase the 
Federal sentencing guidelines for health care fraud offenses. Despite 
the enormous losses in many health care fraud cases, offenders often 
receive shorter sentences than other white-collar criminals. This lower 
risk is one reason criminals are drawn to health care fraud. By 
increasing the Federal sentencing guidelines for health care fraud 
offenses, we send a clear message that those who steal from the 
Nation's health care system will face swift prosecution and substantial 
punishment.
  The provision provides for a number of statutory changes to 
strengthen fraud enforcement. For example, it would expand the 
definition of a ``Federal health care fraud offense'' to include 
violations of the antikickback statute and several other key health 
care-related criminal statutes, which will allow for more vigorous 
enforcement of those offenses, including making their proceeds subject 
to criminal forfeiture. It also clarifies the intent requirement of 
another key health care fraud statute in order to facilitate effective, 
fair, and vigorous enforcement.
  The managers' amendment also includes our provision amending the 
antikickback statute to ensure that all claims resulting from illegal 
kickbacks are considered false claims for the purpose of civil action 
under the False Claims Act, even when the claims are not submitted 
directly by the wrongdoers themselves. All too often, health care 
providers secure business by paying illegal kickbacks, which needlessly 
increases health care risks and costs. This change will help ensure 
that the government is able to recoup from wrongdoers the losses 
resulting from these kickbacks.
  The Kaufman-Leahy measure gives the Department of Justice limited 
subpoena authority for civil rights investigations conducted pursuant 
to the Civil Rights for Institutionalized Persons Act. This provision 
allows the government to more effectively investigate conditions in 
publicly operated institutions, such as nursing homes, mental health 
institutions, and residential schools for children with disabilities, 
where there have been allegations of civil rights violations.
  These changes will strengthen our ability to crack down on fraud and 
will ultimately result in significant savings that will make health 
care more efficient and more affordable.
  I am also pleased Senator Reid's amendment includes a key reform to 
the False Claims Act that Senator Sanders, Senator Grassley, and I have 
proposed. By fixing the False Claims Act's public disclosure provision, 
we can ensure that we fairly and appropriately empower whistleblowers 
to come forward to expose fraud, which is a crucial way to save the 
government money and ensure the health and well-being of Americans.
  We all agree that reducing the cost of health care for American 
citizens is a critical goal of health care reform. We in Congress must 
do our part by ensuring that, when we pass a health care reform bill, 
it includes all the tools and resources needed to crack down on the 
scourge of health care fraud. This provision is an important part of 
that effort.
  I am also very encouraged that the amendment before us includes a 
measure I proposed with Senator Brown to expand Federal Tort Claims Act 
medical malpractice coverage for free medical clinics. This expanded 
coverage will help free clinics across the Nation continue to provide 
and improve a critical safety net for many Americans.
  In 1996, Congress enacted legislation to cover volunteer medical 
professionals in free clinics with medical

[[Page 32962]]

malpractice liability insurance through the Federal Tort Claims Act. 
This coverage protects volunteer medical staff against liability by 
substituting the Federal Government for an individual defendant. But 
without any explanation in the legislative history, the coverage 
enacted in 1996 failed to provide coverage for others who are essential 
to the operation of free clinics, such as nonmedical staff, 
contractors, board members, and the clinic itself. As a result, free 
clinics must use scarce funding to purchase insurance on the private 
market to fill this gap. This lack of comprehensive coverage for free 
clinics is inconsistent with the coverage provided to community health 
centers, which benefit from coverage for all employees. This provision 
will remedy this discrepancy.
  This measure will have no impact on the legal rights of a patient 
injured by a medical error; any victim of medical malpractice will 
still be able to pursue a remedy for an injury under the Federal Tort 
Claims Act. Instead, this amendment will free up scarce resources that 
are currently being used to purchase liability insurance on the private 
market. Informal estimates indicate that this amendment could save free 
clinics across the country $15 to $20 million a year. These are funds 
that will be redirected to providing essential medical services to low-
income and other Americans in need. For example, as a result of this 
amendment, the Viola Startzman Free Clinic in Wooster, OH, will save 
$17,000 a year. The Americares Clinic in Stamford, CT, will save 
$31,000 each year. Our hard-working free clinics in Vermont will save 
$12,000 each year and will be able to put those savings toward helping 
Vermonters in need of health care services. For free clinics operating 
through volunteerism and private donations and in a difficult economy, 
these are substantial sums that if devoted to the care of Americans in 
need will have a significant positive impact.
  And the savings realized through this amendment will cost the 
taxpayers little if anything. Free clinics do not perform high-risk 
procedures such as obstetrics or surgeries, and thus are subject to a 
lesser risk of liability. Since 2004, when funds were first 
appropriated and set aside to cover any claims against free clinic 
doctors, no claims have been filed. The bottom line is that this 
amendment represents significant value to Americans in need of health 
care services at little cost to the government and the taxpayer.
  I thank Senator Brown for his support as a cosponsor, and I thank the 
majority leader, Senator Harkin, and Senator Baucus for working with me 
to make this amendment part of the historic legislation before the 
Senate.
  Over the course of the past month, I have listened to many of my 
friends on the other side of the aisle. It is not surprising that 
frequently they have argued for one of their pet proposals--medical 
malpractice reform. For as long as I have served in this Chamber, I 
have fought against court-stripping measures that limit American's 
access to their justice system. I have also fought to protect the 
sovereignty of States to make rules for their own justice systems. 
Medical malpractice claims are based on State law and for the most part 
take place in State courts. I find it curious that some of the same 
Senators who pledge loyalty to federalism and the sovereignty of the 
States under the tenth amendment are some of the same Senators who are 
so aggressively pushing for a Federal ``one-size-fits-all solution'' 
for the justice systems in our 50 States.
  The managers' amendment includes a provision addressing malpractice 
liability that has been introduced on a bipartisan basis several times 
over the past few years. I support this provision because it respects 
the States' primary role in adjudicating the claims of patients injured 
or killed by medical errors. I also support this provision because it 
resists the notion that ``one-size-fits-all'' when it comes to 
litigation issues and it includes the necessary safeguards for 
patients. I note for the Record that several States' efforts to reform 
medical malpractice liability have been struck down as 
unconstitutional. For example, Alabama, Florida, Georgia, Illinois, 
Kansas, New Hampshire, Ohio, Oregon, South Dakota, Washington, and 
Wisconsin have all enacted caps on damages associated with medical 
malpractice claims. And all of those State laws were struck down as 
unconstitutional for good reason. I am heartened that no such amendment 
was seriously considered in this Chamber because such arcane measures 
hurt our children, our senior citizens, and stay-at-home moms. The Wall 
Street Journal has reported on this clear fact when it pointed out that 
these caps deprive these groups of access to justice. If we create 
Federal caps on their ability to recover from serious injuries we are 
telling them that they are worth less because they are retired or they 
choose to stay home and raise a family or are young children. This is 
not fair. I know that no doctor wants to harm a patient, but the 
solution is not to take away the rights of patients who are seriously 
injured.
  The provision in the managers' amendment does not encourage draconian 
damages caps and does not dictate what reforms States must consider. 
Importantly, however, it does include specific patient protections that 
must be in place before a State can receive a grant for liability 
reform measures. To the extent that States can pass measures that 
improve patient safety as well as expedite damages recovery for 
victims, those reforms will truly improve our health care system.
  I am disappointed, however, that the Health Insurance Antitrust 
Enforcement Act, which I introduced in September, was not part of the 
managers' amendment, and will not be part of the Senate's health reform 
legislation. That legislation would repeal the antitrust exemption for 
health insurers and medical malpractice insurers, and is an integral 
part of injecting competition into the health insurance market.
  While there are differing views on the best way to inject competition 
into the health insurance market, we can all agree that health and 
medical malpractice insurers should not be allowed to engage in 
blatantly anticompetitive practices, such as colluding to set prices 
and allocating markets. My repeal would ensure that basic rules of fair 
competition will apply to insurers, and is nonpartisan.
  My amendment was cosponsored by 23 Senators, and has support from a 
cross-section of consumer rights organization. I look forward to 
working to include this repeal when the Senate and House conference to 
reconcile their versions of the legislation.
  The managers' amendment will improve the underlying bill, and I hope 
my fellow Senators will support its passage so we can move toward final 
passage of the bill. Each day that passes without reform, 30 more 
Vermonters lose their health insurance. We know our current health 
system is unsustainable. That threatens not only our health security, 
but also our economic security. Doing nothing has been seen as an 
option before, but it simply is not an option now.
  I hope now we can work together to pass a bill that will give 
millions more Americans access to quality, affordable health care. We 
should reject the tactics of delay and the efforts to obstruct, and 
remember that the Senate should be the conscience of the Nation. With 
the Christmas season upon us, our constituents are looking to us to do 
the right thing. We should adopt this amendment, advance this 
legislation, and work to send it to the President without undue delay.
  Mr. GRASSLEY. Mr. President, one longstanding priority of mine has 
been to improve Medicare payments for hospitals known as tweeners. They 
tend to have too many beds, so they can't qualify as critical access 
hospitals, but they do not have sufficient volume to operate viably 
under Medicare's prospective payment systems. There are a number of 
these tweener hospitals in Iowa.
  Working closely with the Iowa Hospital Association and individual 
Iowa hospitals over the years, I introduced, last Congress, the Rural 
Hospital Assistance Act of 2008, S. 3300, which would improve the low-
volume adjustment for hospitals under Medicare's hospital inpatient 
prospective payment

[[Page 32963]]

system. This improvement would enable tweener hospitals to benefit from 
this adjustment.
  In fact, the low volume adjustment provision in the Finance 
Committee's health reform bill, S. 1796, and the Reid substitute to 
H.R. 3590 is the language that I crafted. This language was crafted 
with the intention of benefiting all Iowa tweener hospitals. I was 
assured by the Iowa Hospital Association that this language would do 
so, and they supported it.
  Unfortunately, after the Finance Committee markup of S. 1796, I 
learned from the Iowa Hospital Association that the language they 
originally supported would not benefit all Iowa tweener hospitals. I 
was informed that several Iowa tweener hospitals had Medicare 
discharges in excess of the maximum in the provision, which was 1,500.
  In an attempt to make sure that all Iowa tweener hospitals benefit 
from this provision, I filed an amendment that would increase the 
maximum number of Medicare discharges from 1,500 to 1,600. This 
amendment was also offset. My staff was successful in working with the 
majority staff to include my amendment in the manager's amendment to 
the Reid substitute.
  Mr. INHOFE. Mr. President, on Monday morning at 1 a.m., I voted no on 
the cloture motion to the latest Reid managers' package, which was only 
made available Saturday, because I am adamantly opposed to this $2.5 
trillion government-run health care system with its $\1/2\ trillion 
increase in taxes on Americans and nearly $\1/2\ trillion in cuts to 
Medicare to help pay for it. I am opposed to public financing of 
abortion this bill allows. I am opposed to a facade of health care 
reform that in no way seriously addresses tort reform and will only 
increase premiums and the cost of health care for all Americans. I am 
opposed to the special deals for only certain States in this bill to 
buy off votes. I am opposed to the special deals for only certain 
States in this bill to buy off votes. I am opposed to the increased 
burden of at least $26 billion on States including Oklahoma mandated 
under this bill. I am opposed to no serious effort at all to include 
any amendments from Republicans. Republican amendments to block tax 
increases, block cuts to Medicare, impose tort reforms, try to impose 
some kind of discipline on the government take-over of health care in 
this country, among other amendments and motions have failed by nearly 
party-line votes. I am opposed to this bill, and most importantly, the 
American people are opposed to this bill. They know this bill is a 
complete disaster. The next few votes leading up to the final vote on 
this package are all procedural votes, and I will be opposed to them 
all. But all 60 Democrats will vote for them. Democrats do what they 
are told. The votes include accepting this new Reid managers' package, 
cloture on the original Reid substitute, accepting the original Reid 
substitute, cloture on the underlying bill, and finally the final 
passage of his colossal mistake. Since I am opposed to each one of 
these votes, I will not remain in Washington to vote against these 
procedural maneuvers since that will have the same effect as voting no, 
and will return to vote against final passage of this bill.

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