To ensure patients receive doctor recommendations for preventive health services, including mammograms and cervical cancer screening, without interference from government or insurance company bureaucrats.

SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009

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

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

Pending:

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

The ACTING PRESIDENT pro tempore. Under the previous order, there
will be 10 minutes equally divided for the bill managers to speak.
The Senator from Montana.
Mr. BAUCUS. Madam President, I yield myself 2\1/2\ minutes from the
time under the control of the managers.
For the benefit of all Senators I want to take a moment to lay out
today's program.
The time between now and 11:45 is for debate on the amendment by the
Senator from Maryland, Ms. Mikulski, the chairwoman of the Subcommittee
on Retirement and Aging of the Health, Education, Labor and Pensions
Committee.
And at the same time, we will debate the side-by-side amendment by
the Senator from Alaska, Ms. Murkowski.
At 11:45, the Senate will conduct two back-to-back rollcall votes on
the two amendments, first on the amendment by the Senator from
Maryland, and second on the amendment by the Senator from Alaska.
Thereafter, we will conduct approximately 2 hours of debate on the
McCain motion to commit on Medicare and the side-by-side amendment by
the Senator from Colorado, Mr. Bennet.
At 2:45, the Senate will conduct two back-to-back votes on the
amendment by the Senator from Colorado, followed by a vote on the
motion to commit by the Senator from Arizona.
Thereafter, we expect to turn to another Democratic first-degree
amendment and another Republican first-
degree amendment.
This is the fourth day on this bill, and we are only late this
morning coming to our first vote. Even for the U.S. Senate, this is a
slow pace.
I note that some have made plans for delaying this bill in even more
extreme fashion. As the majority leader noted, on Tuesday, one Senator
circulated a list of delaying tactics available under the Senate rules.
I presume all Senators know the Senate's rules already. So to send
the letter leaves the impression that that Senator would like to urge
Senators to use some of the delaying tactics stated in the memo.
But I urge a more cooperative course. Out of courtesy to other
Senators who desire to offer amendments. I urge my colleagues to allow
us to reach unanimous consent agreements to order the voting of future
amendments in a more timely fashion. That is simply the only way that
we can ensure that more colleagues will have the time and opportunity
to offer and debate their amendments.
I thank all Senators.
The ACTING PRESIDENT pro tempore. The Senator has consumed his time.
Mr. BAUCUS. I ask unanimous consent that the order of December 2 be
modified to delete all after the word ``table.''
The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Mr. BAUCUS. I ask unanimous consent that the debate time from 2 to
2:45 this afternoon be divided as follows in the order listed: the
first 17\1/2\ minutes under the control of Senator McCain or his
designee; the next 17 minutes under the control of Senator Baucus or
his designee; and the final 10 minutes, 5 minutes each for Senator
McCain and Senator Bennet of Colorado.

[[Page S12266]]

The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
The Senator from Iowa.
Mr. HARKIN. Madam President, I heard the distinguished minority
leader earlier in his comments say that one of the reasons they are
slowing this bill down and having all this debate is it has been a
strictly partisan venture thus far. I beg to differ with the minority
leader.
I see our distinguished ranking member of the HELP Committee here on
the floor. In the HELP Committee, for the enlightenment of Senators, we
had 13 days of markup, 54 hours, 788 amendments were filed, 287
amendments were considered and debated and voted on or accepted, and
161 Republican amendments were adopted. No one was denied the
opportunity to offer any amendment, to discuss them, debate them, and
get a vote or have it accepted, whatever the case might be. To me, this
is truly a bipartisan way of proceeding.
The minority leader's argument basically goes to the fact that the
people of this country overwhelmingly elected Democrats to guide and
make changes for the future. One of the biggest changes is in our
health care system. One of the responsibilities of being a majority
party is to propose. That is what we have done. We are proposing
changes in the health care system. The function of the minority is to
offer amendments, constructive amendments, offer different ideas, and
if their ideas are better or if they receive majority approval, then
the bill is thus changed. That happened in the HELP Committee. As I
said, 161 Republican amendments were adopted. To me, that is
bipartisan. That is what we have been doing. What is kind of not
acceptable is this idea that things are just going to slow down for the
purposes of delaying and eventually making sure we don't have a bill.
Let me say that after all that lengthy debate we had in the HELP
Committee, we passed a bill. The same will happen here on the Senate
floor. I don't care how many times the minority wants to drag it out
and slow it down to try to kill this bill, this bill will pass the
Senate, we will go to conference, and we will have it on the
President's desk early next year.
The ACTING PRESIDENT pro tempore. The Senator from Wyoming.
Mr. ENZI. I appreciate the comments, some of which need correction,
from yesterday and those that have just been made.
On a partisan bill, I sat through all of those days in the HELP
Committee. That bill was rushed and put together. Senator Kennedy was
not able to be involved in that part of it. His staff did it. They did
it in a hurry. We turned in 159 amendments that were accepted. Most of
those were for typos and minor corrections. There were a few that
actually had some substance to them. That bill was passed on July 15
out of committee without a single Republican vote. It wasn't published.
We didn't see the final version until September 17. The ones that were
really something that could have made a difference were taken out
without the permission of any Republican Senator. That is not
bipartisan.
We talked about how many hours we spent together. If you don't accept
things from the minority party, it is not bipartisan. It is still
partisan. Just spending hours doesn't make any difference.
To move on to a different topic, yesterday we were talking about
costs. I hope the people take a look at a Wall Street Journal article
from yesterday that says:

A bill that raises prices but lowers costs, and other
miracles.

We heard all day yesterday that this bill is going to save people a
lot of money. This article reads:

We have now reached the stage of the health-care debate
when all that matters is getting a bill passed, so all news
is good news, more subsidies mean lower deficits, and more
expensive insurance is really cheaper insurance. The
nonpolitical mind reels.
Consider how Washington received the Congressional Budget
Office's study Monday of how Harry Reid's Senate bill will
affect insurance costs, which by any rational measure ought
to have been a disaster for the bill.
CBO found that premiums in the individual market will rise
by 10% to 13% more than if Congress did nothing. Family
policies under the status quo are projected to cost $13,100
on average, but under ObamaCare will jump to $15,200.
Fabulous news! ``No Big Cost Rise in U.S. Premiums Is Seen in
Study,'' said the New York Times, while the Washington Post
declared, ``Senate Health Bill Gets a Boost.'' The White
House crowed that the CBO report was ``more good news about
what reform will mean for families struggling to keep up with
skyrocketing premiums under the broken status quo.'' Finance
Chairman Max Baucus chimed in from the Senate floor that
``Health-care reform is fundamentally about lower health-care
costs. Lowering costs is what health-care reform is designed
to do, lowering costs; and it will achieve this objective.''
Except it won't. CBO says it expects employer-sponsored
insurance costs to remain roughly in line with the status
quo, yet even this is a failure by Mr. Baucus's and the White
House's own standards.
Meanwhile, fixing the individual market--which is expensive
and unstable largely because it does not enjoy the favorable
tax treatment given to job-based coverage--was supposed to be
the whole purpose of ``reform.'' Instead, CBO is confirming
that new coverage mandates will drive premiums higher. But
Democrats are declaring victory, claiming that these higher
insurance prices don't count because they will be offset by
new government subsidies.
About 57% of the people who buy insurance through the
bill's new ``exchanges'' that will supplant today's
individual market will qualify for subsidies that cover about
two-thirds of the total premium. So the bill will increase
costs but it will then disguise those costs by transferring
them to taxpayers from individuals. Higher costs can be
conjured away because they're suddenly on the government
balance sheet. The Reid bill's $371.9 billion in new health
taxes are also apparently not a new cost because they can be
passed along to consumers, or perhaps will be hidden in lost
wages. This is the paleo-
liberal school of brute-force wealth redistribution, and a
very long way from the repeated White House claims that
reform is all about ``bending the cost curve.'' The only
thing being bent here is the budget truth.
Moreover, CBO is almost certainly underestimating the cost
increases. Based on its county-by-county actuarial data, the
insurer WellPoint has calculated that Mr. Baucus's bill would
cause some premiums to triple in the individual market. The
Blue Cross Blue Shield Association came to similar
conclusions. One reason is community rating, which forces
insurers to charge nearly uniform rates regardless of
customer health status or habits. CBO doesn't think this will
have much of an effect, but costs inevitably rise when
insurers aren't allowed to price based on risk. This is why
today some 35 states impose no limits on premium variation
and six allow wide differences among consumers.
The White House decided to shoot messengers like WellPoint
to avoid rebutting their message. But Amanda Kowalski of MIT,
William Congdon of the Brookings Institution and Mark
Showalter of Brigham Young have found similar results. In a
2008 paper in the peer-reviewed Forum for Health Economics
and Policy, these economists found that state community
rating laws raise premiums in the individual market by 20.9%
to 33.1% for families and 10.2% to 17.1% for singles. In New
Jersey, which also requires insurers to accept all comers
(so-called guaranteed issue), premiums increased by as much
as 227%.
The political tragedy is that there are plenty of reform
alternatives that really would reduce the cost of insurance.
According to CBO, the relatively modest House GOP bill would
actually reduce premiums by 5% to 8% in the individual market
in 2016, and by 7% to 10% for small businesses. The GOP
reforms would also do so without imposing huge new taxes. But
Democrats don't care because their bill isn't really about
``lowering costs.'' It's about putting Washington in charge
of health insurance, at any cost.

The ACTING PRESIDENT pro tempore. The time of the Senator has
expired.
Under the previous order, the time until 11:45 a.m. shall be equally
divided between the Senator from Maryland, Ms. Mikulski, and the
Republican leader or his designee.
Mr. HARKIN. Madam President, parliamentary inquiry: There is time
between now and the hour of 11:45 a.m. equally divided between the
Republican side and the Democratic side; is that correct?
The ACTING PRESIDENT pro tempore. That is correct.
Mr. HARKIN. Madam President, I assume, then, the normal thing will be
to go back and forth from one side to the other, the Republican side
and the Democratic side?
The ACTING PRESIDENT pro tempore. That will not be an order unless it
is propounded.
Mr. BAUCUS. Madam President, I think it is perfectly understood.
Mr. ENZI. That is our understanding as well.
Mr. HARKIN. Madam President, I ask unanimous consent to be recognized
for 7 minutes.

[[Page S12267]]

The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Mr. BAUCUS. Madam President, will the Senator yield for a quick
inquiry to my friend from Wyoming?
Mr. HARKIN. Yes.
Mr. BAUCUS. Madam President, I might inquire of my colleague from
Wyoming if that item the Senator was quoting from about costs in the
Wall Street Journal was a news article or an editorial.
Mr. ENZI. That was an editorial by the Wall Street Journal, the staff
of the Wall Street Journal, confirmed by MIT, Brigham Young, and
others.
Mr. HARKIN. Madam President, I ask if the Chair will remind me when
the 7 minutes is up.
The ACTING PRESIDENT pro tempore. The Chair will do so.
Mr. HARKIN. Madam President, I have to respond to my friend from
Wyoming about doing this in a hurry. He mentioned that we did the bill
in a hurry in our committee. Actually, it was last November, shortly
after the election, when I received a call from Senator Kennedy talking
about doing a health reform bill, asking if I would take charge of a
section dealing with public health and prevention and wellness. I think
then he asked Senator Murray to take over workforce development,
Senator Bingaman did coverage, and Senator Mikulski did quality
improvements. So that was in November.
I cannot speak for the others who did the other sections. All I can
say is, on our side, in what I did, we had five hearings. We had five
hearings on public health and prevention and wellness and what ought to
go into a bill. I think those hearings commenced in December and went
through about February. Then we worked until June, and we did not start
our markup until June. So we had almost 6 months of hearings and
putting things together in the bill before we started a markup. I
rather doubt that can be said to be rushing anything.
But I just want to focus on the vote that is coming up on the
amendment offered by the Senator from Maryland, Ms. Mikulski, which
will strengthen provisions in the bill concerning preventive health
benefits for women.
As an initial matter, I am proud of the significant investments the
bill makes overall in wellness and prevention. It has not been talked
about very much. If you read the public press out there, the popular
press, and watch TV, about the only thing you think is in the bill is a
public option and abortion and that is what this bill is about. Well,
those may be the hot points and the flashpoints--it makes for good
press--but I submit that one of the most important parts, if not the
most important part, of this bill is what it does for prevention and
wellness, trying to move our costs upstream, keeping people healthy in
the first place.
I have said many times, what good does it do us if we are just going
to pour more money into paying bills for a broken, dysfunctional, sick
care system--not a health care system, a sick care system? That is what
we have in America today. This bill begins the transformation of moving
us from a sick care system to a true health care system.
The Senator from Maryland has a very important amendment to make
clear--to make clear--that what is included in the bill is to
strengthen the preventive services that basically inure to the women of
this country. The Mikulski amendment reiterates the recommendations of
our bill, and it also points out that the recommendations of the U.S.
Preventive Services Task Force is a floor, not a ceiling--it is a
minimum. In other words, health plans are required at a minimum to
provide first-dollar coverage for preventive services recommended by
the Preventive Services Task Force, but that is just the minimum. The
Secretary of Health and Human Services has full discretion to identify
additional preventive services that will be part of the essential
package offered by health insurance on the exchange.
Again, there has been some talk here about this task force, the
Preventive Services Task Force, that somehow this is a bunch of
bureaucrats, it is a government-run task force, it has a political
agenda. I have heard all these things said on the floor in the last day
or so. Well, in fact, the Preventive Services Task Force is an
independent body that evaluates the benefits of clinical preventive
services. It makes recommendations--again, no decisions, merely
recommendations--about which services are most effective.
Who is on this task force? Experts and leaders in primary care who
are renowned internists, pediatricians, family physicians,
gynecologists, and obstetricians. And these professionals are not
located in Washington, DC; they are based all over the country. Some
may be in one State or another State. They are all over the country,
and they are experts in these different areas, recognized by their
peers. They do not sit in an office at Health and Human Services. They
bring years of medical training and experience to the jobs they do.
Does that mean they never make a mistake? No. No one is perfect. No
Senator is perfect. Neither is every doctor perfect. And neither is any
task force always going to make what we might consider to be the
perfect answer. But our bill does not grant them the authority to tell
insurance companies what not to cover. That is clear. But to hear the
debate on the floor, you would think it is just the opposite, that the
Preventive Services Task Force can tell insurance companies what they
cannot cover. That is not true. Our bill says that those
recommendations that are A and B--categorized by the Preventive
Services Task Force, by these expert doctors around the country--these
are the ones they say really are key preventive services, have the most
benefit. We say in our bill that those services must be covered without
copays, without deductibles. That means that is the floor. That is the
floor.
Again, I might also add that preventive services that are rated by
the Advisory Committee on Immunization Practices and comprehensive
guidelines supported by the Health Resources and Services
Administration are also part of the recommendations to establish that
floor.
So, again, I would say it is a pretty big floor when you put all
those together. Again, it does not establish a ceiling and it does not
say what cannot be done. It just says you have to do these basics. That
is the floor.
I do understand the concerns of some that the task force has not
spent enough time studying preventative services that are unique to
women. Senator Mikulski goes back a long way on this issue. I can
remember some years ago Senator Mikulski pointing out to me, in my
capacity as the then-chairman of the Appropriations subcommittee that
funds NIH----
The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Mr. HARKIN. Madam President, I ask unanimous consent for 3 more
minutes.
The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Mr. HARKIN. Senator Mikulski said: If you look at the research being
done at NIH, it is almost all done on men and not on women. I remember
that some years ago, and all of a sudden a lightbulb went off in my
head. I said: You are right. So we had to start changing the focus of a
lot of the research done to focus on the unique situations faced by
women.
Well, this was also a concern that was raised in our HELP Committee
by Senator Mikulski, and we included language to require all health
plans to cover comprehensive women's preventive care and screenings
based on guidelines promulgated by the Health Resources and Services
Administration--again, without any copays or deductibles. That was in
our health bill but unfortunately was not included in the merged bill.
But Senator Mikulski's amendment, which we are about to vote on, brings
us back to the position we had in the HELP Committee bill. I think that
was largely supported, if I am not mistaken, on both sides, at least in
our HELP Committee. At least no one offered any amendment to strike it
when we were debating it in committee. So I assume it was supported
generally by both Republicans and Democrats.
By voting for the Mikulski amendment, we can make doubly sure that
the floor we are establishing in the bill for preventive services that
are unique to women also has no copays and no deductibles. Again, that
is why this amendment is so important.

[[Page S12268]]

I know our friend Senator Murkowski has a different way of approach.
I commend her for her involvement and her interest in this issue. She
has been a great member of our committee, and I have done a lot of
great work with Senator Murkowski. But I think her amendment misses the
mark in this way: It asks insurers to use guidelines from provider
groups when making coverage decisions. Well, that does not guarantee
women will get any of the preventive services they need.
Here is a statement from the American Heart Association and the
American Stroke Association. It says:

. . . we are concerned that Senator Murkowski's preventive
health services amendment would take a step backwards by
substituting the judgment of the independent U.S. Preventive
Services Task Force with the judgment of private health
insurance companies.

Madam President, I ask unanimous consent that this letter from the
American Heart Association and the American Stroke Association be
printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

Statement by American Heart Association CEO Nancy Brown on Murkowski
Amendment on Preventive Health Services

(Dec. 2, 2009)

The American Heart Association strongly supports requiring
health plans and Medicare to provide first-dollar coverage
for clinical preventive services that are evidence-based and
necessary for the prevention or early detection of an illness
or disability. We appreciate that Senator Murkowski's
amendment recognizes the value of the guidelines and
recommendations made by professional medical organizations
(as well as by voluntary health organizations like the
American Heart Association). But even these guidelines must
be held to the standard of being evidenced based. In
addition, we are concerned that Senator Murkowski's
preventive health services amendment would take a step
backwards by substituting the judgment of the independent
U.S. Preventive Services Task Force with the judgment of
private health insurance companies. Although we have
previously recommended to Congress that the USPSTF membership
be expanded to include specialists to broaden the expertise
of the Task Force, we believe an expanded USPSTF would be the
best entity to objectively and rigorously make
recommendations for covering clinical preventive services and
do not support eliminating it from this role.

The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Mr. HARKIN. Madam President, I will have more to say about the
Murkowski amendment later. But, again, the point is, the Mikulski
amendment is right on point. It should be adopted.
The ACTING PRESIDENT pro tempore. Who yields time?
Mr. ENZI. Madam President, I yield 10 minutes to the Senator from
Florida.
The ACTING PRESIDENT pro tempore. The Senator from Florida.
Mr. LeMIEUX. Madam President, I come to the floor today to draw back
the curtain a little, I hope, and to widen the lens to talk about the
issue of the bill before us, not just on this particular amendment but
on what it is going to mean for my constituents in Florida and for the
people of this country.
I had the opportunity last week to be back home in Florida, in south
Florida, in Palm Beach County and Broward County and Miami-Dade County,
where I talked to doctors, hospital administrators, folks who run
Medicare Advantage plans, as well as everyday Floridians, specifically
senior citizens. The responses I heard were nearly unanimous, and that
was grave concern about the bill that is being debated on this floor
and a general confusion as to why the Congress is pursuing the path
that it is. The people of Florida do not understand why we are going to
cut Medicare to create a new program. The people of Florida do not
understand why we are going to raise taxes to create a new program. The
people whom I have spoken to in Florida do not understand why we would
undertake a new $2.5 trillion health care proposal if it was not going
to reduce the cost of health insurance for the 170 million to 180
million Americans who have health insurance today.
Why are we embarking upon this measure if it is not going to affect
most everyday Floridians and everyday Americans who are struggling
under the high cost of health insurance? Health insurance premiums have
increased 130 percent in the past 10 years.
When the President put this proposal forward and when he campaigned
on it, he said his major goal was to reduce the cost of health
insurance. When he addressed the Nation in a joint session of Congress
on September 9, he said his plan would reduce the cost of health
insurance. But we find out that for at least 32 million Americans, it
will raise the cost of health insurance 10 to 13 percent. So at least
half of the goal, if not most of the goal, of his plan for most
Americans in this country will not be accomplished. Yet we are going to
cut nearly $\1/2\ trillion out of Medicare, we are going to raise taxes
by $\1/2\ trillion, and we are going to spend $2.5 trillion on this
program, which was admitted to by Senator Baucus yesterday on the
floor, which cannot be, under my understanding, in any way budget
neutral.
But I want to speak specifically about the cuts to Medicare. It cuts
$192 billion, according to the Congressional Budget Office, ``to
Medicare's payment rates for most services.'' I think we have to be
clear here that if you cut providers, you are going to cut services.
The very reason we talked about increasing doctor payments in that $\1/
4\ trillion program was so that patients would not receive fewer
services, so there would be ample doctors providing services for
Medicare. It is beyond logic to argue that cutting providers will not
cut services. What will happen when we cut providers, doctors, nursing
homes, home health agencies, hospitals? Fewer and fewer of them will
provide benefits, and fewer and fewer of them will take Medicare.
The Chief Actuary of CMS believes the cuts in the bill we have before
us could cause providers to end their participation in Medicare:

. . . providers for whom Medicare constitutes a substantive
portion of their business could find it difficult to remain
profitable and might end their participation in the program.

Every American understands this. If we pay less money to health care
providers, they are going to offer less benefits or more and more they
are not going to participate in Medicare.
The Medicare Payment Advisory Commission found in June of last year
that 29 percent of Medicare beneficiaries who were looking for a
primary care doctor had a problem finding one to treat them. This is of
grave concern to the 3 million Floridians who are on Medicare. If a
doctor will not see them, what kind of health care plan is this? These
seniors, our ``greatest generation,'' have paid into this program their
whole life. It is illusory if they can't find a doctor who will treat
them.
One of my constituents, Earl Bean, from Sanford, FL, recently told
CNN that he called about 15 doctors when he was trying to find health
care, and he was told they were not taking new Medicare patients. So
when we cut $\1/2\ trillion out of Medicare, is that going to improve
health care for seniors or is it going to continue to decline health
care for seniors? You can't get blood from a stone. It is going to make
the situation worse. For anyone to come to this floor and say that it
would not is incredible.
We have in Florida the second highest Medicare population. When we
cut $135 billion from hospitals and $21 billion from the
disproportionate share fund, which is basically money that goes to
these hospitals to provide health care for seniors and the indigent,
how are they going to be able to provide that health care? I spoke to
the administrator of the North Broward Hospital District and told him
about this cut to the DSH funds, and he told me it would be devastating
to their provision of health care.
Then we are going to take a very popular program called Medicare
Advantage--more than 900,000 Floridians in my State--and we are going
to cut it as well. I recently visited the Leon Medical Center and their
new facility in Miami Dade County where they provide state-of-the-art,
first-class health care for seniors; not only normal health care but
eyeglasses, hearing aids, dental care, and the constituents who go
there love it. They are getting the kind of health care that you would
hope your senior citizens in your family would get.
The principal of the company, Ben Leon, told me they have saved $70
billion in the way they have run their system. He told me if we
continue on this path with these cuts to Medicare Advantage, he will
not be able to provide

[[Page S12269]]

these good services going forward. There are some fixes to grandfather
folks in, but all in all people will be cut, and all in all the program
will not be as good, and it will decline the health care of seniors in
Florida and across this country.
We will cut $15 billion from nursing home care and $40 billion from
home health agencies. I spoke to a provider of a home health agency
practice in Florida. He said these cuts will put half of the home
health care agency folks out of business. At a time when we have 11.2
percent unemployment in Florida, this health care bill is going to cost
people their jobs, and it is going to decline the quality of health
care.
I am also concerned about this Medicare advisory board. This
independent board of nonelected folks is going to have the power to cut
Medicare by $23 billion over the next 10 years, and it will be up to
this body to reinstate those cuts. These people are not elected, my
constituents in Florida don't know who they are, but they are going to
be responsible for the decline of their Medicare and their health care.
The ``greatest generation,'' who fought to protect this country, is
looking at this health care bill and wondering why. Folks with health
insurance in this country--more than 170 million who are not going to
see their health care costs go down but up--are wondering why.
Americans who are seeing higher taxes and penalties for not buying
these health insurance programs under this bill are wondering why.
If we are here to reform health care--and we should be--if we are
here to try to make sure the 45 million people in this country and the
nearly 4 million Floridians get health insurance--and we should be--
then why don't we take a step-by-step approach?
I am new to this body. My first day here was September 10, so I have
not even been here 3 months. But I can tell my colleagues, the American
people, if they knew what I know now and could see what I see, would be
baffled by this process. There is not a give-and-take on this issue. We
didn't all sit down together in a conference room and work this out to
have a bipartisan bill. The Democratic leader worked on it with his
colleagues but not with us.
So now we have a program that cuts Medicare, that raises taxes, that
doesn't decrease the cost of health care for the majority of Americans
and will cost us $2.5 trillion and can't be budget-neutral, at a time
when we have a $12 trillion debt, a debt that requires each of us--each
family--to put $100,000 on our shoulders to be responsible for that
debt, a debt where the third largest payment in our budget is for
interest payments, and over the next 10 years those interest payments
will go up by $500 billion, enough to pay for many of the budgets of
the Federal Government----
The ACTING PRESIDENT pro tempore. The Senator has used his 10
minutes.
Mr. LeMIEUX. Including the wars in Afghanistan and Iraq.
I thank the Chair, and I yield the floor.
The ACTING PRESIDENT pro tempore. The Senator from Maryland is
recognized.
Mr. HARKIN. How much time would the Senator like to consume?
The ACTING PRESIDENT pro tempore. The Senator from Maryland controls
the time, and the Senator from Maryland has 33 minutes.
Ms. MIKULSKI. Madam President, I yield myself a firm 10 minutes.
The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Ms. MIKULSKI. Madam President, health care is a woman's issue. Health
care reform is a must-do woman's issue, and health insurance reform is
a must-change issue.
So many of the women and men of the Senate are here today to fight
for change and to make sure we have universal access to health care.
When we have universal access, it makes a difference in our lives,
which means we have to have universal access to preventive and
screening services.
My amendment--and, by the way, it is a bipartisan amendment--makes
universal access to preventive and screening services for women
available.
There is much discussion about whether women should get a particular
service at a particular age. We don't mandate that women get a service;
we leave that up to a decision made with the woman and her doctor. But,
first of all, they need to be able to have a doctor. So we are for
universal access, and this is why the underlying bill is so important.
Then, when you have that, there should also be universal access to
preventive and screening services, particularly to the top killers of
women, those things that are unique to women. We think about cancer:
breast cancer, ovarian cancer, and cervical cancer. Also, women are
dying at an increased rate of lung cancer. Then there are these other
silent killers that have had a lethal effect on women, and that is
cardio and vascular disease. So we want to guarantee universal access
to medically appropriate or medically necessary screening and
preventive services.
Many women don't get these services because, first of all, they don't
have health insurance; and, No. 2, when they do have it, it means these
services are either not available unless they are mandated by States or
the copayments are so high that they avoid getting them in the first
place.

The second important point about my amendment is it eliminates
deductibles and copayments. So we eliminate two big hurdles: having
insurance in the first place, which is the underlying bill, as well as
copayments and deductibles. I know of no one in this room who would not
want to be on our side on this issue.
I wish to acknowledge the role the Senator from Alaska has played,
Ms. Murkowski, as well as Senator Kay Bailey Hutchison, Senator Snowe,
and Senator Collins. We, the women of the Senate, have worked on a
bipartisan basis for years making sure we were included in the
protocols at NIH, increasing funding for important research areas to
find that cure, to race for that cure and, at the same time, to be able
to have mammogram standards. What the Murkowski amendment--and by the
way, she is Murkowski, I am Mikulski. We sound alike, and the
amendments might sound alike, but, boy, are they different.
The Murkowski amendment offers information. I think that is
important. That is a threshold matter. You have to have information to
make an informed decision. But it does not guarantee universal access
to these services, and, of course, it does not eliminate the high
payments and deductibles. So her amendment is flawed. My amendment is
terrific. My amendment offers key preventive services, including an
annual women's health screening that would go to a comprehensive
assessment of the dangers to women, including heart disease and
diabetes.
We hope when the Senate makes its decision today, it deals with the
fact that for we women, the insurance companies take simply being a
woman as a preexisting condition. We face so many issues and hurdles.
We can't get health care. We can't get health insurance because of
preexisting conditions called a C-section.
I am going to be meeting with an insurance company executive later
where his company denied health insurance to a woman who had a
medically mandated C-section, and a letter from this insurance company
said: We are not going to give you insurance unless you have a
sterilization--a coerced sterilization in the United States of America.
That is going to be an amendment for another day. But I just wish to
give the flavor and the power of what women face when we have to cope
with the insurance companies or where there are barriers to our getting
these health care screening services.
So we want to be able to save lives, and we want to be able to save
money. We believe in universal access, and if you utilize the service
it is because you have had the consultation with your doctor. We do
know early screening and detection does save lives, and, at the same
time, it saves money.
I will conclude with this: When we look at heart disease and
diabetes, not only cancer but early detection of diabetes means, in a
well-managed program, under appropriate medical supervision you very
likely will not lose that eye, you will not lose that kidney, you will
not lose that leg and, most of all, you will not lose your life.
So let's not lose the Mikulski amendment. Let's go with Mikulski and
thank Murkowski for her information, but hers is too tepid and too
limited.

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Madam President, I ask my colleague, one of the great guys who
supports us, Senator Cardin, how much time he needs.
I yield 5 minutes to Senator Cardin.
Mr. CARDIN. First, let me thank my colleague, Senator Mikulski, for
her leadership on this issue. I strongly support her amendment for the
reasons she said. This is a very important point about providing
preventive health services to the women of America, a critically
important part of our strategy not only to bring down costs in health
care, but to have a health care system that is fair in America.
I have been listening to my colleagues on the other side of the aisle
talk about the underlying bill. They talk about it as if this is a
static situation. Many of the criticisms I hear about the underlying
bill are criticisms about our current health care system. I can tell my
colleagues the people in Maryland, many of whom are finding it
difficult to find affordable coverage today, are outraged with what is
happening with private insurance companies and the attitudes they are
taking.
As Senator Mikulski pointed out, they are denying coverage for
preexisting conditions or imposing arbitrary caps. As has been
indicated, if we are unable to get this bill passed, what is going to
happen in the future? We know costs are going to become even greater,
more people are going to lose their coverage, insurance companies are
going to continue their arbitrary practices, and the health care of
Americans is in jeopardy.
We are already spending so much of our economy on health care, and if
we don't take action, it will be a greater part of our economy.
But we have some good news. The underlying bill has now been analyzed
by the CBO; that is the independent scorekeeper. What they tell us is,
if we pass the underlying bill, for the overwhelming majority of
Americans, they are going to find that their health insurance premiums
will either stay the same or go down. For the overwhelming majority of
Americans, they will have a better insurance product that will cover
the types of preventive services Senator Mikulski is talking about,
which are in her amendment.
We are not only going to bring down the cost for the overwhelming
majority of Americans as to what will happen if we don't pass a bill,
we are going to provide better coverage for them. The underlying bill
will also reduce dramatically the number of people who don't have
health insurance in America by 31 million. That will make our system
much more effective.
I have heard my colleagues talk about what is going to happen with
Medicare. If we pass the underlying bill, we are going to strengthen
Medicare. We already have a provision that there cannot be reductions
in the guaranteed benefits. We pointed out that AARP endorses the bill.
They understand there will be additional preventive health care for our
seniors, and we will help fill the doughnut hole in prescription drugs.
When you reduce the number of uninsured, the amount of cost Medicare
has to pay for health care in our hospitals is reduced. That is why we
can reduce our payments to hospitals in America, because the amount of
uncompensated care they currently have will be dramatically reduced. I
have heard colleagues on the other side of the aisle talk about
Medicare Advantage. I remember when we used to pay the private
insurance companies in Medicare a little less than people in
traditional Medicare. Then we paid them the same. Now we are paying
them more. That is corporate welfare. Medicare Part B premiums are
higher than they should be. Taxpayer support is higher than it used to
be. We know these benefits that are being paid could be gone tomorrow.
We saw the private insurance companies leave the Maryland market and so
many other markets. These are reforms that save the taxpayers money and
strengthen Medicare for the future.
Bottom line: The bill is good for middle-income families. It will
provide the insurance reform so they have an insurance product that can
cover their needs, including wellness and prevention programs. It is
good for small business because it offers more choice. I can tell you
chapter and verse of small companies in Maryland that, today, cannot
get an affordable product and are seeing 20, 30 percent increases in
their premiums. They need this bill in order to be able to preserve
health care for their employees.
This bill, with the Mikulski amendment, will provide the preventive
health care for all Americans that is so desperately needed, which will
reduce costs, improve quality, and make our health care system more
efficient and effective in the future, bringing down costs by investing
in wellness and prevention.
I urge my colleagues to support the Mikulski amendment and to support
the underlying bill.
I yield the floor.
Mr. ENZI. Madam President, I yield 10 minutes to the Senator from
South Dakota.
The ACTING PRESIDENT pro tempore. The Senator from South Dakota is
recognized.
Mr. THUNE. Madam President, I appreciate the opportunity to speak on
this important piece of legislation.
Again, I point out to my colleagues, and to anybody else who may be
observing, the volume of this bill. This is 2,100 pages and 21 pounds,
which means it is about a pound per 100 pages. It is $1.2 billion
dollars per page, $6.8 million per word, and it creates 70 new
government programs. It gives the Secretary of Health and Human
Services--in 1,600 or 1,700 instances in this bill--the opportunity to
create, define, and determine things in the bill.
This is a big government bill, a massive expansion of the Federal
Government--$2.5 trillion, when it is fully implemented. Of course, the
paid-fors in the bill--all the things in this bill, not only those
intended things but also the unintended consequences of the bill--you
have some revenue to pay for these things. Where do we get the revenue?
In the Reid bill, they decided they are going to raise taxes on small
businesses, individuals and families and they are going to cut Medicare
by about $\1/2\ trillion.
What is ironic about that is, a few years ago, the Republicans, back
when we were in the leadership in the Senate, tried to do a budget bill
that actually achieved some savings in Medicare and Medicaid, to the
tune of $27 billion combined. But the Medicare savings in that bill was
$10 billion. That was over a 5-year period, at $2 billion per year. I
wish to remind some of my colleagues on the other side about some of
the comments they made about that.
Senator Reid, at the time--bear in mind this was to reduce Medicare
by $2 billion per year, $10 billion over 5 years. The now-majority
leader said:

Unfortunately, the Republican budget is an immoral
document.

The Senator from West Virginia said this:

This proposed budget would be a moral disaster of
monumental proportions.

A couple other colleagues in the Senate commented. The Senator from
Michigan said:

People who rely on Medicare and Medicaid are going to be
hurt by this bill.

The Senator from Wisconsin said:

I urge my colleagues to reject this bill, and the
irresponsible and cruel budget of which it is part.

The former Senator from New York, Mrs. Clinton, said this:

This bill slashes $6.4 billion from Medicare over the next
5 years.

It was actually $10 billion. My point is simply this: It was $10
billion over 5 years, $2 billion per year. Those were the statements--
overstatements--about the impact that a $2 billion reduction per year
in Medicare was going to have on people in this country. Now we are
talking about $\1/2\ trillion in Medicare cuts.
Where do their cuts come from? They will come from $118 billion from
Medicare Advantage, which now we have about 11 million Americans
impacted by Medicare Advantage. Every State has seniors who have
subscribed to that program whose benefits will be cut if this bill is
enacted. You get it out of hospitals because there are $135 billion in
reductions and reimbursements to hospitals; $15 billion in reductions
to nursing homes and reimbursements; $40 billion in reductions to home
health agencies; and $8 billion in reductions to hospices.
Those are all the ways this $2.5 trillion expansion of the Federal
Government is to be paid for. I didn't even get into the tax cuts,
which will be a debate for another day.
The Medicare cuts in this bill are unlike anything we have seen in
the past.

[[Page S12271]]

Clearly, when you compare it to 3, 4 years ago, when we were trying to
achieve $10 billion in savings over 5 years, you thought the sky was
falling. Now here they are trying to pay for a $2.5 trillion expansion
of the Federal Government by cutting $500 billion out of Medicare.
The point I also wish to make, because it has been made by the other
side--by the most recent speaker--is that somehow this recent CBO
analysis should be hailed as good news. The corks are popping in the
celebration, and people are crowing about the new CBO report because it
has such good news for this bill and the impact it will have on people
who buy health insurance in this country.
What is it they are celebrating? CBO, in its report, essentially said
this: 90 percent of Americans are going to see their premiums increase
or see virtually the same increases as they do today year after year.
That is preserving the status quo, not decreasing costs, as promised.
President Obama, when he was running for office in 2007, said when he
got a chance to do health care reform, he was going to reduce costs by
$2,500 for every family in this country and cover everybody.
This bill, after spending $2.5 trillion and creating 70 new
government programs, doesn't cover everybody. There are still 24
million Americans who don't get covered under this bill, according to
the CBO. Furthermore, nobody--I shouldn't say nobody--90 percent of
Americans, those who don't get subsidies, don't come out any better.
They will still see the year-over-year increases in premiums they have
been seeing for the past several years, and the cost of health care is
growing at twice the rate of inflation. If you assume a year-over-year
increase similar to the past several years, in the small group market,
you are looking at annual increases of over 6 percent for the cost of
health care--to the point where a family that, today, is paying $13,000
a year for health insurance, in 2016, will pay over $20,000 a year for
health insurance. So nobody gets any better out of this, except a
handful of people who will get subsidies. If you are in the individual
marketplace, your premiums go up. According to the CBO, there will be a
10- to 13-percent increase in premiums in the individual market. If you
are in the large group market, you will see an almost 6-percent
increase a year. If you are in the small group market, premiums will go
up over 6 percent a year.
We are talking about spending $2.5 trillion, cutting reimbursements
to nursing homes, to hospitals, to home health agencies and hospices,
and raising taxes on health care providers, medical device
manufacturers, prescription drugs, raising the Medicare payroll tax
which, incidentally, doesn't go to preserve or extend the lifespan of
Medicare or put it on a path toward sustainability but creates a whole
new government entitlement.
We are going to do all that for what? At best, to keep the status quo
for people today; at worst, to increase their premiums by 10 to 13
percent. That is the bottom line. That is what this says. That is the
new CBO report. That is the CBO report about which the other side is
saying this is great news. They are celebrating. It is great news that
premiums are going to continue to go up at twice the rate of inflation,
just like in the past, protecting and preserving the status quo as we
know it in America today.
This bill does nothing about the fundamental issue of cost. It
doesn't matter what market you are in--small group market, large group
market--it stays the same, at best, and in the individual marketplace,
your premiums will go up 10 to 13 percent. That is the news being
hailed by the other side as validating the argument for why we need to
pass a 2,100-page, $2.5 trillion monstrosity of a bill with 70 new
government programs in it.
We will vote on the Medicare amendment later. Senator McCain has a
motion to commit the bill to essentially take the Medicare cuts out of
it. I hope my colleagues vote for it. They are arguing it doesn't cut
Medicare. How can you say that with a straight face? How can you say
you are going to find $500 billion to pay for this bill out of Medicare
and then say it doesn't cut Medicare? Of course it cuts Medicare. Of
course it raises taxes. You can't finance $2.5 trillion of new spending
unless you find a way to finance it.
The way they have chosen to finance this is to hit seniors squarely
between the eyes and cut reimbursements to the providers all across
this country that are dealing with the serious health needs our senior
citizens are experiencing. In South Dakota, we have a lot of people who
are employed in the health care industry. I think that is true of every
State. Even in small towns in South Dakota, in nursing home employment
you are talking about almost 6,000 employees. You are going to take $15
billion out of nursing homes, $40 billion out of home health agencies,
$135 billion out of hospitals, and what we are talking about are huge
reductions in Medicare, unlike anything we have seen.
As I said, to put it into perspective, a few short years ago, when we
were in the majority, in a budget trying to reduce Medicare by $10
billion over a 5-year period, it was referred to as ``immoral,'' as a
``monumental disaster,'' as ``cruel''--$10 billion over 5 years. This
has $\1/2\ trillion in Medicare cuts--cuts to Medicare Advantage and
providers.
I hope my colleagues will support the McCain motion.
I yield the floor.
Ms. MIKULSKI. Madam President, I yield 3\1/2\ minutes to the junior
Senator from Minnesota, Mr. Franken.
The ACTING PRESIDENT pro tempore. The Senator from Minnesota is
recognized.
Mr. FRANKEN. Madam President, I rise to express my support for
Senator Mikulski's amendment for women's health.
This amendment is crucial because it is about prevention. Prevention
is one of the key ways this bill will transform our system of sick care
into true health care. It is common sense. You get the right screenings
at the right time so you find diseases earlier. It saves lives and it
saves money.
The Senate bill already has several provisions for preventive care,
which I strongly support. For example, colonoscopies and screening for
heart disease will be covered at no cost. It is a good start.
The current bill relies solely on the U.S. Preventive Services Task
Force to determine which services will be covered at no cost. The
problem is, several crucial women's health services are omitted.
Senator Mikulski's amendment closes this gap. Under her amendment, the
Health Resources and Services Administration will be able to include
other important services at no cost, such as the well woman visit,
prenatal care, and family planning.
These preventive services will truly improve women's health. For
example, if all women got the recommended screening for cervical
cancer, we could detect this disease earlier and prevent four out of
every five cases of this invasive cancer. This will improve the health
of our mothers, sisters, and our daughters. This bill and this
amendment will make prevention a priority and not an afterthought.

Although I respect the efforts of my distinguished colleague from
Alaska, the Murkowski alternative falls short. The Murkowski amendment
does nothing to guarantee women will have improved access to coverage
and cost-sharing protections for preventive services. Rather than
establish objective, scientific standards about which preventive
services should be covered, this alternative only requires insurers to
consult with medical organizations when making coverage decisions.
While we know the U.S. Preventive Services Task Force recommendations
do not cover all necessary services, the Murkowski amendment entirely
removes even this basic coverage requirement from the bill, leaving
women without any protections under health care reform for essential
preventive care. This means that important preventive care for women,
including screening for osteoporosis and sexually transmitted
infections, may not be covered by insurance plans.
In the simplest terms, the Murkowski amendment maintains the status
quo, and we know the status quo is not working for millions of women
who are forgoing preventive care because they simply cannot afford it.
The Murkowski amendment continues to leave prevention coverage
decisions up to health insurance companies, and that means there would
be no guarantee

[[Page S12272]]

that any health plan will cover basic preventive services at all.
Do we want to leave these important decisions up to the insurance
companies? The health of American women is too important to leave in
their hands. That is why I urge my colleagues to support Senator
Mikulski's amendment and vote to make sure women can get the preventive
screenings they need to stay healthy. Most important, this amendment
will make sure women have access to these lifesaving screenings at no
cost.
The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Mr. FRANKEN. I request another 45 seconds.
The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Mr. FRANKEN. Madam President, prevention is just one of the ways this
bill will improve women's health. It also ends insurance companies'
practice of charging women more because they happen to be women, or
denying coverage based on a history of pregnancy, C-section, or
domestic violence.
We need to pass this bill this year to ensure comprehensive,
affordable care for women throughout the country. And we need to
include this amendment because I want to be able to look my wife in the
eye, I want to be able to look my daughter in the eye--my son, too--and
my future grandchildren in the eye and say we did everything we could
in this bill to improve women's health. We cannot wait any longer. I
urge all my colleagues to stand with us and support this amendment.
I yield the floor.
Mr. ENZI. Madam President, I yield 5 minutes to the Senator from
Oklahoma.
The ACTING PRESIDENT pro tempore. The Senator from Oklahoma.
Mr. COBURN. Madam President, it is interesting, as a practicing
physician who has actually cared for women and nobody so far who has
been in on this debate has ever done. I congratulate the Senator from
Maryland for her care about prevention because we all know that is key.
The mischaracterization we heard about this bill is astounding. The
reason we got in trouble with the Preventive Task Force is because it
did something that was inappropriate and did not have the appropriate
professional groups on its task force when it made its recommendation
on breast cancer screening.
The Murkowski amendment says we will rely on the professional
societies to make the determinations of what must be available. We have
heard the Senator from Iowa say health insurance will decide that. That
is absolutely untrue. Health insurance will not decide it. The
professional societies will decide what will be covered, and the
insurance companies must cover it under the Murkowski amendment.
The second point is there will not be any objective criteria. The
objective criteria doctors practice under today are the guidelines of
their professional societies.
Here is the difference between the Murkowski amendment and the
Mikulski amendment: The Senator from Maryland relies on the government
to make the decision on what will be covered. She refers to the Health
Resources and Services Administration. She refers to the Health
Resources and Services Administration which has no guidelines
whatsoever on women's health care right now, other than prenatal care
and childcare. That is the only thing they have.
For whom does HRSA work? HRSA works for the Secretary of Health and
Human Services. So the contrast between these two amendments could not
be any more clear in terms of do we want to solve the problems we just
experienced on mammogram recommendations? We can let the government
decide, which got us into this trouble, and they will set the practice
guidelines and recommendations for screening or you can let the
American College of Obstetricians and Gynecologists or the American
College of Surgeons or the American College of Oncologists set and use
their guidelines.
The choice is simple: The government can decide what care you get or
the people who do the care, the professionals who know what is needed,
who write the peer-reviewed articles, who study the literature and make
the recommendations for their guidelines.
Every month I get from the American College of Obstetricians and
Gynecologists their new guidelines. I try to follow them at every
instance. The fact is, the Mikulski amendment says government will
decide. That is what it says. The government will decide through HRSA.
The Murkowski amendment says it is the best practices known by the
physicians who are out there practicing. What is the difference? How
does it apply to you as a woman? It applies to you as a woman because
the people who know best get to make the recommendations rather than a
government bureaucracy. That is the difference.
If you will recall, under the stimulus bill we passed, we have a cost
comparative effectiveness panel, which will surely be in the mix
associated with the recommendations. If you look at what the task force
on preventive recommendations said from a cost standpoint, they were
absolutely right. From a patient standpoint, they were absolutely
wrong.
The real debate on this bill--the Mikulski amendment is the start of
the real debate--is do we have the government decide based on cost or
do we have the professional caregivers who know the field decide based
on what is best for that patient. That is the difference.
What the Senator from Alaska does, which is necessary, is she says we
will rely on the American College of Obstetrics and Gynecology. We will
rely on the American College of Surgeons. We will rely on the American
College of Oncologists to determine what should be the screening
recommendations for patients.
For, you see, what happens with the Mikulski amendment is the
government stands between you and your doctor. That is what is coming.
That is what will be there.
There is no choice under the Murkowski amendment for an insurance
company to have the option either to cover or not to cover. They must.
It says ``shall'' do that. So the mischaracterizations on what the
Murkowski amendment actually says and does are unfortunate.
The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Mr. COBURN. I yield the floor.
The ACTING PRESIDENT pro tempore. Who yields time?
The Senator from Maryland.
Ms. MIKULSKI. Madam President, how much time does our side have?
The ACTING PRESIDENT pro tempore. There is 17 minutes 15 seconds
remaining.
Ms. MIKULSKI. I yield 5 minutes to the Senator from Michigan.
The ACTING PRESIDENT pro tempore. The Senator from Michigan.
Ms. STABENOW. Madam President, first, I thank Senator Mikulski for
her leadership not only on this important amendment but on so many
issues in health care, issues for women across this country. We are
honored to call her dean for all of us as it relates to focusing on the
issues that are so critical to women and their families.
I thank Senator Reid for making this a priority and making this the
first amendment we are offering in this debate.
We all know that often women are the ones making health care
decisions for their families as well as themselves. They are more
likely to be the person making health insurance choices. Women of
childbearing age pay on average 68 percent more for their health care
than men do. We have so many instances in which insurance companies are
standing between women and their doctors right now in making
decisions--decisions not to cover preventive services, such as a
mammogram screening or a cervical cancer screening, decisions to call
pregnancy a preexisting condition so women cannot get health insurance,
decisions not to cover maternity care so that women and their babies
can get the care they need so that babies can be successful in life,
both prenatal care and postnatal care.
Women of this country have a tremendous stake in health care reform.
We pay more now, if we can find coverage at all, and there are too many
ways in which insurance companies block women from getting the basic
health services they need.
This amendment is critically important to make sure that women are
able

[[Page S12273]]

to get preventive care services without a deductible and without
copays. This amendment recognizes the unique health needs of women. It
requires coverage of women's preventive services developed by women's
health experts to meet the unique needs of women.
Why do we stress that? We stress that because for years we have
struggled in so many areas to make sure that women's health needs were
focused on and not just health in general. When we look at research
through the National Institutes of Health and what it took to get to a
place where research would be done for women on women's subjects or on
female mice or rats rather than male subjects to make sure that the
differences between men and women were considered in research, we have
made important steps in that direction. Again, Senator Mikulski was
leading the way as it relates to having a women's health research
effort in our country.
This is one more step to make sure we are covering women's preventive
services developed by women's health experts for the unique needs of
women. That is what this is all about--making sure women have access to
preventive services such as cervical cancer screenings, osteoporosis
screenings, annual mammograms for women under 50, pregnancy and post
partum screenings, domestic violence screenings, and annual checkups
for women.
We know more women die of heart disease than actually any other
disease. This is something I do not think is widely known. We have even
heard that many physicians do not realize the extent to which heart
disease is prevalent in women. All of us women have worked together on
a women's heart bill and part of that is for screenings. Part of that
is to make sure we are screening for heart disease and strokes, the No.
1 killer of women. This would make sure those screenings would be part
of health care reform.
I could go on to list all the different prevention items, but I will
simply say that when we are talking about women's health and we are
talking about women's lives, this is an incredibly important amendment
to adopt.
The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Ms. STABENOW. I yield the floor.
Mr. ENZI. Madam President, I yield 5 minutes to the Senator from
Texas.
The ACTING PRESIDENT pro tempore. The Senator from Texas.
Mrs. HUTCHISON. Madam President, I rise to speak on the Mikulski
amendment and the Murkowski amendment because I feel very passionate
about women's issues. In fact, Senator Mikulski and I have worked
throughout my time in the Senate and her time before me on these very
issues--assuring that women's health care concerns, which are different
from men's in many instances, are a part of any health care coverage in
our country, and ongoing we must assure the same.
I have been an advocate for cancer screening services for women, and
I was dismayed when I saw the U.S. Preventive Services Task Force a few
weeks ago issuing new guidelines for cancer screening for women--breast
cancer screening for women. We have all lived with breast cancer
throughout the course of the history of women, but especially in the
last probably 25 years the strides that we have made in saving lives
and in the survivability of women with breast cancer is because we have
had early detection. We don't have a cure for breast cancer, and we are
all fighting for that cure, but until we get it, the first line of
defense is early detection.
So now we have a new task force recommendation that says everything
we have had and enjoyed over the last 25 years in saving women's lives
is no longer relevant because now, before the age of 50, you don't need
a mammogram, and after the age of 50 it is every other year.
Well, I know Senator Mikulski and I agree we do not think that is
right. Neither did any other woman in the Senate when that was proposed
years ago by President Clinton. We all stood up and said no. I am
standing up and I am saying no once again, and I am sure every woman in
the Senate is, as many women in America are.
But the Mikulski amendment doesn't actually fully address the problem
of having the task force--which is relied on 14 times in the bill
before us--as the arbiter of what is necessary for our government
program and that it then will surely become the private sector standard
as well. That task force even has money allocated to advertize its task
force recommendations. So rather than the Mikulski amendment severing
the ties with the task force, the amendment now has another government
agency that has the same capability to basically interfere between the
woman and her doctor, which is where we want the decisions to be made.
Coverage decisions will be dictated by both the task force and a new
Health Resources and Services Administration entry into the mix.
While I certainly agree with Senator Mikulski about the importance of
preventive services for women and insurance coverage decisions, I can't
support her amendment because we still have not one but two government
task forces and committees that will be in the middle of these health
care coverage decisions. I think the coverage decisions should be made
by doctors and their patients. That is why I have joined with Senator
Murkowski in offering the alternative approach. This is what we should
expect from any future health care reform, and it is certainly what we
expect today.
The Murkowski amendment will leave the medical decisions to the
guidelines established by those who know medical treatment best, which
is our own doctors. In fact, we have just received a CBO assessment of
what the Murkowski amendment would cost, and it actually says there
will be a savings. So rather than the Mikulski amendment, which would
spend $1 billion over 10 years, the Murkowski amendment would actually
save $1.4 billion over 10 years. Why? Because the Murkowski amendment
relies on the combined commonsense and clinical judgment of American
physicians.
The ACTING PRESIDENT pro tempore. The Senator's time has expired.
Mrs. HUTCHISON. So, Madam President, I urge a vote for the Murkowski
amendment. I know we have the same goals as Senator Mikulski and her
amendment, but I don't believe the Mikulski amendment achieves the goal
of having a woman and her doctor make the decisions for her. That is
the key that I think is so important in this debate. I urge a vote for
the Murkowski amendment.
I thank the Chair, and I yield the floor.
The ACTING PRESIDENT pro tempore. Who yields time?
Ms. MIKULSKI. Madam President, I yield 4 minutes to the Senator from
the State of Washington, who has been a real leader on these issues.
By the way, Madam President, before the Senator speaks, I want to
thank Senator Stabenow for a unique courtesy. This is her desk, and as
many of my colleagues know, I broke my ankle and I can't get up to
where my desk is at this point. I will, however, in a matter of another
few weeks. But she has given me this desk on loan so that I could stand
on my own two feet to debate this amendment, and I wanted to thank her
for the courtesy.
Madam President, I also want to note something while the senior
Senator from the Republican leadership is here, and the author of the
amendment. We, the women of the Senate, on a bipartisan basis, have
worked for women's health. Today, we disagree on what is the best way
to achieve it by these two amendments. I want to thank my colleagues
for setting a tone of civility. I think this has been one of the most
rational, civilized conversations we have had over this, and I would
like to thank them.
As the leader on this side of the aisle, in terms of seniority, I
would like to extend my hand in friendship and suggest when this bill
is done, and this amendment is done, we continue to focus on this
wonderful work that we have done together. We have done things that
have saved millions of lives, and so I look forward to continuing that.
Madam President, I now yield 4 minutes to the Senator from the State
of Washington, Mrs. Murray.
The ACTING PRESIDENT pro tempore. The Senator from Washington.
Mrs. MURRAY. Madam President, I thank my colleague from Maryland, and
I would just say that wherever she stands on the floor of the Senate,
she leads us all. So we are delighted you are here and thank you so
much for

[[Page S12274]]

your leadership on this critical issue of making sure women have access
to quality preventive health care services and screenings which are so
critical to women across the country.
Madam President, the Senator from Maryland offered this amendment,
and I worked with her in the committee. She has been a leader on this
for many years, and I echo her comments as well that this has always
been an issue. For as long as I have been here--since 1993--the women
in the Senate, on both sides of the aisle, have stood up to make sure
that women's care is part of health care, and we understand we have to
stand shoulder to shoulder. It is unfortunate at this time that we see
this in a little different light, but I agree with Senator Mikulski. We
will keep working together throughout our time here to make sure
women's preventive services are covered.
I do support the Mikulski amendment and the Mikulski approach. Her
amendment requires all health plans to cover comprehensive women's
preventive care and screenings at no cost to women. I just wanted to
come to the floor for a minute and point out why this is so important.
When the economy is hurting, women on the whole tend to think of
caring for their families first and not caring for themselves. They
take care of their children and their spouses first, and they end up
delaying or skipping their own health care in order to take care of
their families. In fact, we know in 2007, a quarter of women reported
delaying or skipping their health care because of cost. In May of 2009,
just 2 years later, a report by the Commonwealth Foundation found that
more than half of women today are delaying or avoiding preventive care
because of its cost.
That is not good for women, it is not good for their families, and it
is not good for their ability to be able to take care of their families
and to take care of themselves. So Senator Mikulski's amendment is
extremely important, especially in this economic time. We know if women
get the preventive care and care for their needs, then they are able to
care for their families. Yet the situation we find ourselves in today
is that women are not taking preventive care. They are not taking care
of themselves. Therefore, when they get sick, they end up in the
hospital and then their families are in trouble. So we know preventive
services can save lives, and it means better health outcomes for women.
We have to make sure we cover preventive services, and this takes
into account the unique needs of women. Senator Mikulski's amendment
will make sure this bill provides coverage for important preventive
services for women at no cost. Women will have improved access to well-
women visits--important for all women; family planning services;
mammograms, which we have all talked about so many times, to make sure
they maintain their health.
Madam President, I want to emphasize that this amendment preserves
the doctor-patient relationship and allows patients to consult with
their doctors on what services are best for them. This has become a
large topic of conversation over the last several weeks, and Senator
Mikulski's amendment makes sure if a woman under 50 decides to receive
an annual mammogram, this amendment will cover it. She will be able to
work with her own doctor and take care of her health.
So, Madam President, I come to the floor today to strongly support
the Mikulski amendment, to thank her for her leadership, and I hope we
can get to and vote on this important issue and move on and pass health
care reform.
My constituents, when I go home, say: Move on. Get this done. We have
to take care of this because of our economy, because of the impact on
small businesses, because of the rising costs of premiums, and because
of the large number of people who are losing their health care
coverage. This health care bill is going to make a major difference
when we get it passed, and the American public can take a deep breath
and say: Finally, our government has moved forward.
So let's get past this amendment. I support strongly the Mikulski
amendment. Let's move on this bill and take a major step forward for
health care coverage for all Americans and pass the health care bill.
Madam President, I yield the floor.

Abortion

Mr. CASEY. Madam President, may I ask the Senator from Maryland to
yield for a question about her amendment, No. 2791 to H.R. 3590, the
purpose of which is to clarify provisions relating to first dollar
coverage for preventive services for women?
Ms. MIKULSKI. Of course.
Mr. CASEY. Senator Mikulski had a similar amendment in the HELP
Committee bill and at that time, I commended the Senator on its
substance as I am a strong supporter of preventive care for women. I
thank her for offering this important amendment and particularly for
calling our attention to the importance of first dollar coverage of
preventive services for women.
Ms. MIKULSKI. I thank the Senator.
Mr. CASEY. Particularly in view of some of the recent controversy
about mammograms and coverage, I am particularly grateful that the
Senator has clarified this with this amendment and allow for the fact
that preventive services must preserve the doctor-patient relationship.
Thus, women under 50 may decide with their doctor that they should have
a mammogram screening and this amendment would ensure coverage of such
service.
Ms. MIKULSKI. That is correct.
Mr. CASEY. There is one clarification I would like to ask the
Senator. I know we discussed it during the HELP markup and it was not
clarified at that time and thus I chose to vote against the amendment
because of the possibility that it might be construed so broadly as to
cover abortion. But I understand that the Senator has now clarified
specifically that this amendment will not cover abortion in any way.
Specifically, abortion has never been defined as a preventive service
and there is neither the legislative intent nor the language in this
amendment to cover abortion as a preventive service or to mandate
abortion coverage in any way. I ask the Senator is that correct?
Ms. MIKULSKI. Yes, that is correct. This amendment does not cover
abortion. Abortion has never been defined as a preventive service. This
amendment is strictly concerned with ensuring that women get the kind
of preventive screenings and treatments they may need to prevent
diseases particular to women such as breast cancer and cervical cancer.
There is neither legislative intent nor legislative language that would
cover abortion under this amendment, nor would abortion coverage be
mandated in any way by the Secretary of Health and Human Services.
Mr. ENZI. Madam President, I yield 2 minutes to the Senator from
Kansas.
Mr. BROWNBACK. Madam President, I rise in support of the amendment of
the Senator from Alaska, and I have talked with my good friend, the
Senator from Maryland, Ms. Mikulski, about a side issue in this overall
debate about what is included in the definition of preventive care. The
Senator from Maryland stated in a colloquy that ``there are no abortion
services included in the Mikulski amendment.'' She has stated that in
colloquy.
I have trouble, however, because I believe a future bureaucracy could
interpret it differently. So I asked my friend from Maryland if she
would include clear legislative language in this saying simply:

Nothing in this Act shall be construed to authorize the
Secretary, or any other governmental or quasi-governmental
entity, to define or classify abortion or abortion services
as ``preventive care'' or as a ``preventive service.''

I think that clarifies the issue, and it would be my hope that my
colleague from Maryland would include that in her language. It is not
in there, even though there have been statements on the floor. But, as
we all know as legislators, it is one thing to say something on the
Senate floor, and it is one thing to have a colloquy, but it is far
different to have it written in the base law. This is not in the base
law.
So I would urge my colleague, the Senator from Maryland, to include
this language. Absent that, I think there is too much room for a
broader definition of what preventive care means; that it could include
abortion services as well, and I would urge my colleagues to vote
against the Mikulski amendment if that is the case.
On that ground, I think there are other issues involved, and that is
why I think the approach of the Senator from

[[Page S12275]]

Alaska is superior, while maintaining the doctor-patient privilege. I
think this is a good debate for us to have, given these recent
discussions. But absent this change, I think there is another issue
that is involved that I would urge my colleagues to consider.
Madam President, I want to yield back to maintain some time for the
Senator from Wyoming to be able to speak, so I yield the floor.
Mr. FEINGOLD. Madam President, disappointed that the Senate health
care debate has gotten off on the wrong foot. The first amendment voted
on would add almost a billion dollars to our budget deficits over the
next 10 years. We should make sure health plans cover women's
preventive care and screenings, but we should also find a way to pay
for it, rather than adding that cost to the already mountainous public
debt. At a time of record deficits, Americans expect fiscal
responsibility from their representatives in Congress.
The PRESIDING OFFICER (Mr. Kirk). Who yields time?
Ms. MIKULSKI. Mr. President, we are waiting for Senator Boxer to come
to the floor, so if the other side of the aisle has another speaker, I
know at the end we hope that Senator Lisa and Senator Barb--I say that
because our last names sound so much the same--could wrap it up.
How would the Senator from Wyoming like to proceed? We are waiting
for Senator Boxer or for Senator Baucus.
Mr. ENZI. Mr. President, I yield 10 minutes to the Senator from
Alaska so she can actually propose her amendment that we have been
debating and take up to 10 minutes.
Ms. MIKULSKI. Then I will wrap up.
Mr. ENZI. That would still leave us with 2 minutes. If it does leave
us with 2 minutes, then I would have the Senator from Wyoming use that
2 minutes.
Ms. MIKULSKI. Whatever way it will work and accommodate you while we
are waiting to see who our speakers are.
The PRESIDING OFFICER. The Senator from Alaska is recognized.
Ms. MURKOWSKI. Mr. President, I want to start my comments by
acknowledging my colleague from Maryland and accept her gracious offer
to continue to work on this issue as it relates to women's health and
women's health services. As has been noted by the Senator from Maryland
and the Senator from Washington, this is an issue that we women of the
Senate have come together on repeatedly, to work cooperatively. While
we do have, some would say, somewhat dueling amendments here, I think
it is important to recognize the goals we are both seeking to attain
here are certainly right in alignment. We are just choosing different
means to get there. But I appreciate, again, the civility and
cooperation from not only Senator Mikulski but the other women of the
Senate on this very important issue.
I wish to reiterate a couple of points about my amendment that I made
yesterday.
The PRESIDING OFFICER. The Senator from Maryland.
Ms. MIKULSKI. Mr. President, I fear the microphone of the Senator
from Alaska is not working.
Ms. MURKOWSKI. Is that better?
Ms. MIKULSKI. That is so much better. I want to hear about the
amendment and continue our conversation.
Ms. MURKOWSKI. The Senator just missed all the kind remarks I
directed to her attention.
Ms. MIKULSKI. I ask unanimous consent she be extended an additional 2
minutes. No, I withdraw that request.
Ms. MURKOWSKI. I will make sure those comments that were made for the
Record will be delivered to the Senator personally.
I want to reiterate some points I made yesterday about my amendment
and I will also share with my colleagues, I know the Senator from Texas
mentioned it as well, the CBO score we received late last evening. It
provides us with a score showing a cost savings of $1.4 billion over
the next 10 years. I think this is significant, as Members, certainly
from the other side, raised the importance of fiscal discipline and our
fiduciary responsibility here. Importantly, the CBO indicated the
provisions on the second page which prevent the Secretary from using
the recommendations of the USPSTF to deny coverage would cost money
which means we are protecting certain benefits and that is very
important.
The amendment we will have before us, the Murkowski amendment, is one
that allows or requires a level of transparency with the recommended
health screenings, prevention services that are deemed necessary not by
some task force that is appointed by folks within the administration,
not by some commission that has political relationships. What we are
urging is that the health screenings, the preventive services, be
determined by those who are actually in the field, those
practitioners--those who are engaged in oncology, OB/GYNs. We need to
be looking to the experts. We need to be looking to that peer-reviewed
science. We don't need to be looking to those entities that have been
brought together by a government entity or by the Secretary. We need to
be looking to the likes of the American Society of Clinical Oncology,
the American College of Surgeons, the American College of Radiation
Oncology, the American College of Obstetrics and Gynecology. We need to
look to their recommendations.
Again, as I mentioned yesterday in my comments, if you go to their
Web sites, if you look to their specific recommendations, they will
give guidance, guidance that, again, is based on their practice in
oncology, their practice as an OB/GYN. Look to what they set out as the
guidelines for cervical cancer screening, for mammograms, and let that
information be made available publicly through the pamphlets, the plans
that come together from the insurance companies. But allow them--allow
me, as a consumer of health care, me as a consumer looking for the best
plan for me and my family--to know what those guidelines are, not from
a government task force but from those who are the real experts. I
think this is the transparency that health care shoppers are looking
for.
Some have suggested: Lisa, your amendment doesn't require the
insurance companies to provide any prevention or screening services.
There is no mandate in there. If we do not have a mandate, then the
insurance companies are not going to provide health care prevention and
screening services.
I think we need to ask the question here, what is the point of
prevention? It is to prevent more expensive care in the future by
preventing the chronic and more acute illnesses. So should not the
insurance companies want to utilize more preventive services, utilize
more screenings, more wellness services, in order to keep down the
costs of care based on the judgment of the doctors, based on the
judgment of the professionals, and not necessarily those who, again,
are part of a government entity?
I know within my staff I have a member who is on the FEHBP plan, but
they contact her on a somewhat regular basis about her diabetes care,
ensuring she is taking her medications, getting the necessary
preventive services offered by her insurer for her particular
condition.
It has been mentioned by several of my colleagues that this USPSTF is
not such a bad group of guys, they are not just these nameless,
faceless bureaucrats. I think it is important to recognize, and even
the American Heart Association has recognized it, that the Preventive
Services Task Force is limited to only primary care doctors and not
specialists such as the oncologists, the cancer doctors who see
patients every day battling cancer. These doctors who are providing
Americans with their suggestions on what services are necessary for
cancer screenings, but yet these doctors are not part of this task
force, have again shone the spotlight on what happens when you have a
government entity or government task force that is basically the one
saying this is what is going to be covered, this is not what is going
to be covered. In my amendment, we specifically provide that the
recommendations from USPSTF cannot be used to deny coverage of an item
or service by a group health plan or health insurance offeror. I think
that is very important.
I think it is also important to recognize that what we do in my
amendment is make sure the health plans consult the recommendations and
guidelines of the professional medical organizations to determine what
prevention benefits should be covered by these health insurance plans
throughout the country.

[[Page S12276]]

We also require plans to provide this information directly to the
individuals. You get to see it for yourself. You get to make that
determination. So what that means is the doctors and the specialists
will be recommending what preventive services to cover, not those in
Washington, DC.
My amendment ensures that the Secretary of Health and Human Services
shall not use any of the recommendations, again made by the task force,
to deny coverage. We also include broad protections to prevent
bureaucrats at the Department of Health and Human Services from denying
care to patients based on comparative effectiveness research. And
finally, we have a provision that ensures the Secretary of Health and
Human Services may not define or classify abortion or abortion services
as preventive care or as preventive services.
The PRESIDING OFFICER. The time of the Senator has expired.
Ms. MURKOWSKI. I appreciate that. I think my amendment is
straightforward. I think it is a good compromise and again it is a
clear differential between what we are going to do to allow a woman to
have full choice with her doctor as opposed to government telling us
who we should be seeing.

Amendment No. 2836 to Amendment No. 2786

Mr. President, I ask consent to call up my amendment, No. 2836.
The PRESIDING OFFICER. The clerk will report the amendment.
The assistant legislative clerk read as follows:

The Senator from Alaska [Ms. Murkowski] for herself, Mrs.
Hutchison, and Mr. Johanns, proposes an amendment numbered
2836 to amendment No. 2786.

Ms. MURKOWSKI. I ask unanimous consent that further reading of the
amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment is as follows:

(Purpose: To ensure patients receive doctor recommendations for
preventive health services, including mammograms and cervical cancer
screening, without interference from government or insurance company
bureaucrats)

On page 17, strike lines 11 through 14.
On page 17, line 15, strike ``(2)'' and insert ``(1).''
On page 17, line 20, strike ``(3)'' and insert ``(2)''.
On page 17, between lines 24 and 25, insert the following:

``Notwithstanding any other provision of law, the Secretary
shall not use any recommendation made by the United States
Preventive Services Task Force to deny coverage of an item or
service by a group health plan or health insurance issuer
offering group or individual health insurance coverage or
under a Federal health care program (as defined in section
1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)))
or private insurance.
``(b) Determinations of Benefits Coverage.--A group health
plan and a health insurance issuer offering group or
individual health insurance coverage shall, in determining
which preventive items and services to provide coverage for
under the plan or coverage, consult the medical guidelines
and recommendations of relevant professional medical
organizations of relevant medical practice areas (such as the
American Society of Clinical Oncology, the American College
of Surgeons, the American College of Radiation Oncology, the
American College of Obstetricians and Gynecologists, and
other similar organizations), including guidelines and
recommendations relating to the coverage of women's
preventive services (such as mammograms and cervical cancer
screenings). The plan or issuer shall disclose such
guidelines and recommendations to enrollees as part of the
summary of benefits and coverage explanation provided under
section 2715.''.
On page 17, line 25, strike ``(b)'' and insert ``(c)''.
On page 18, lines 3 and 4, strike ``or (a)(2)''.
On page 18, line 4, strike ``(a)(3)'' and insert ``(a)(2)''
On page 18, line 11, strike ``(c)'' and insert ``(d)''.
On page 124, between lines 22 and 23, insert the following:
(d) Rule of Construction With Respect to Preventive
Services.--Nothing in this Act (or an amendment made by this
Act) shall be construed to authorize the Secretary, or any
other governmental or quasi-governmental entity, to define or
classify abortion or abortion services as ``preventive care''
or as a ``preventive service''.
On page 1680, strike lines 10 through 12, and insert the
following:
``(A) to permit the Secretary to use data obtained from the
conduct of comparative effectiveness research, including such
research that is conducted or supported using funds
appropriated under the American Recovery and Reinvestment Act
of 2009 (Public Law 111-5), to deny coverage of an item or
service under a Federal health care program (as defined in
section 1128B(f)) or private insurance; or''.

The PRESIDING OFFICER. The Senator from Montana is recognized.
Mr. BAUCUS. Mr. President, I am going to speak very briefly on the
pending subject and then let the sponsor of the amendment, that is the
Mikulski amendment, finish up here. I think it is very telling--I know
this point has been made before but I think it bears repeating--the
American Heart Association, American Stroke Association has written and
released to the Senate this letter. I will read the most important part
here. Basically they say they strongly support requiring health plans
and Medicare providing first dollar coverage for clinical preventive
services that are evidence based and necessary for the prevention or
early detection of an illness or disability. We all agree with that.
They go on then to comment on the Murkowski amendment, saying they
appreciate the Murkowski amendment recognized the value of the guidance
and recommendations but they go on to say that even these guidelines
must be held to a standard of being evidence based.
I might say, I run across this over and over again in the medical
profession--medical experts. We need to keep moving more and more
toward evidence-based medicine.
This statement from the American Heart Association, American Stroke
Association, goes on to say:

In addition, we are concerned that Senator Murkowski's
preventive health services amendment would take a step
backwards by substituting the judgment of the independent
U.S. Preventive Services Task Force with the judgment of
private health insurance companies.

Frankly, it is a point I very much agree with. I don't think we want
the judgment of private health insurance companies making these
decisions. I think it is appropriate the sponsor of the amendment
finish. She is doing a very good job.
Mr. ENZI. I will yield our final minute to the Senator from Wyoming.
The PRESIDING OFFICER. The Senator from Wyoming is recognized.
Mr. BARRASSO. Mr. President, my wife Bobbi was diagnosed with breast
cancer by a screening mammogram in her forties. It is that screening
mammogram that has saved her life. By the time of the mammogram, the
tumor had spread and she has had two operations and two full bouts of
chemotherapy. I do not want a government bureaucrat making a decision
for the women of America if they should be allowed to have screening
mammograms. It saves lives--1 in 1900, for women in their 40s.
The Reid bill empowers bureaucrats to decide what preventive benefits
will be allowed for American women. The amendment from the Senator from
Maryland does the same--bureaucrats, not the physicians who are doing
the treating. That is why I support the amendment of the Senator from
Alaska, because that amendment says the Federal Government cannot use
recommendations of the U.S. Preventive Services Task Force,
recommendations from bureaucrats, to deny care to anyone including
seniors on Medicare--anyone in America. That is how this decision
should be made, not by government bureaucrats.
I yield the floor.
The PRESIDING OFFICER. The Senator from Maryland is recognized.
Ms. MIKULSKI. Mr. President, how much time is there on our side?
The PRESIDING OFFICER. The Senator has 3 minutes.
Ms. MIKULSKI. Mr. President, I yield myself 3 minutes.
As we get ready to conclude the debate on both the Mikulski as in
Barbara Mikulski and Murkowski as in Lisa Murkowski amendments, I want
to first say a word about the Senator from Alaska. We have worked
together on the Health, Education, Labor and Pensions Committee. We
have worked together as women of the Senate, to provide access to
women's health services. Not too long ago, when I had my awful fall,
she gave me much wisdom and counsel and practical tips because she
herself had broken her ankle. To us, when you say to Senator Lisa or
Senator Barb, ``Break a leg,'' it has a whole different meaning. I
again thank her for all her work. I have great respect for her. I look
forward to our continued working together.

[[Page S12277]]

But I do sincerely disagree with her amendment because what her
amendment does is, it guarantees, really, only information. It does not
guarantee universal access to preventive and screening services.
It also does not remove the cost barriers by eliminating the high
deductibles for the copayments when you go to get a preventative or
screening service. It tells insurance companies to give information on
recommended preventative care. That is a good thing, but it is a
threshold thing. You need to have universal access to the service.
In addition, we do not mandate that you have the service; we mandate
that you have access to the service. The decision as to whether you
should get it will be a private one, unique to you. We leave it to
personalized medicine. So in the poignant case of the wife of the
Senator from Wyoming, it would have been up to the doctor, the
physician, to get her the service she needed.
It is not only I or one side of the aisle that is opposing the
Murkowski amendment. The American Cancer Society, the American Heart
Association, and the American academy of GYN services oppose it.
My amendment is a superior amendment because it guarantees universal
access to preventative and screening services. It also eliminates one
of the major barriers to accessing care by getting rid of high payments
and deductibles. It doesn't say you will have a mammogram at 40
because, again, we are substituting ourselves for the task force; it
says you will have universal access to that mammogram if you and your
doctor decide it is medically necessary or medically appropriate.
Vote for Mikulski. Don't vote for Murkowski. And please, on this one,
get it straight.
The PRESIDING OFFICER. Under the previous order, the question is on
agreeing to amendment No. 2791 offered by the Senator from Maryland,
Ms. Mikulski, as amended.
Ms. MIKULSKI. I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There appears to be.
The clerk will call the roll.
The assistant legislative clerk called the roll.
The result was announced--yeas 61, nays 39, as follows:

[Rollcall Vote No. 355 Leg.]

YEAS--61

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

NAYS--39

Alexander
Barrasso
Bennett
Bond
Brownback
Bunning
Burr
Chambliss
Coburn
Cochran
Corker
Cornyn
Crapo
DeMint
Ensign
Enzi
Feingold
Graham
Grassley
Gregg
Hatch
Hutchison
Inhofe
Isakson
Johanns
Kyl
LeMieux
Lugar
McCain
McConnell
Murkowski
Nelson (NE)
Risch
Roberts
Sessions
Shelby
Thune
Voinovich
Wicker
The PRESIDING OFFICER (Mr. Burris). On this vote, the yeas are 61,
the nays are 39. Under the previous order requiring 60 votes for the
adoption of this amendment, amendment No. 2791, as amended, is agreed
to. Under the previous order, the motion to reconsider is considered
made and laid upon the table.

Amendment No. 2836

Under the previous order, there will now be 2 minutes of debate,
equally divided, prior to a vote in relation to amendment No. 2836,
offered by the Senator from Alaska, Ms. Murkowski.
The Senator from Maryland.
Ms. MIKULSKI. Mr. President, I rise in opposition to the Lisa
Murkowski amendment. Though well-intentioned, it does not guarantee
universal access to preventive and screening services for women. It
does not remove the cost barriers of high payments and codeductibles.
It is opposed by the American Cancer Society and the American Heart
Association. It primarily provides information on those matters.
We salute her intention, but we think her amendment is too limited,
and, to quote the American Heart Association, it would be an actual
``step backwards'' in the area of making preventive services available,
particularly not only in the matter of cancer but in heart and vascular
disease--the emerging No. 1 killer for women.
I urge defeat of the Murkowski amendment.
The PRESIDING OFFICER. The Senator's time has expired.
The Senator from Alaska.
Ms. MURKOWSKI. Mr. President, the purpose of this amendment is to
ensure we do not have government entities that are making those
decisions we as individuals working with our doctors feel is best.
The intent behind this amendment is to ensure that those medical
professional organizations, whether it is the American Society of
Clinical Oncology or the American College of Surgeons or the American
College of Radiation Oncology or the American Society of Obstetricians
and Gynecologists--those who are in the practice, those who are making
the recommendations--these are the individuals we want to know are
being consulted, not some entity that has been created by those of us
in the government or by some administration, by some Secretary.
So what we propose with this amendment is an insurance offering, if
you will. You will know fully what is part of your plan. It is you and
your doctor making these decisions.
I urge a ``yes'' vote on this amendment.
Mr. ENSIGN. Mr. President, I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second? There appears to
be.
The question is on agreeing to the Murkowski amendment.
The clerk will call the roll.
The bill clerk proceeded to call the roll.
The result was announced--yeas 41, nays 59, as follows:

[Rollcall Vote No. 356 Leg.]

YEAS--41

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

NAYS--59

Akaka
Baucus
Bayh
Begich
Bennet
Bingaman
Boxer
Brown
Burris
Byrd
Cantwell
Cardin
Carper
Casey
Conrad
Dodd
Dorgan
Durbin
Feingold
Feinstein
Franken
Gillibrand
Hagan
Harkin
Inouye
Johnson
Kaufman
Kerry
Kirk
Klobuchar
Kohl
Landrieu
Lautenberg
Leahy
Levin
Lieberman
Lincoln
McCaskill
Menendez
Merkley
Mikulski
Murray
Nelson (FL)
Pryor
Reed
Reid
Rockefeller
Sanders
Schumer
Shaheen
Specter
Stabenow
Tester
Udall (CO)
Udall (NM)
Warner
Webb
Whitehouse
Wyden
The PRESIDING OFFICER. On this vote, the yeas are 41, the nays are
59. Under the previous order, requiring 60 votes for the adoption of
amendment No. 2836, the amendment is withdrawn.
Mr. NELSON of Nebraska. Madam President, this afternoon I voted
against the amendment offered by my colleague, the senior Senator of
Maryland, Ms. Mikulski.
I voted against this amendment with regret because I strongly support
the underlying goal of furthering preventive care for women, including
mammograms, screenings, and family planning. Unfortunately, the
amendment did not incorporate language I suggested to specifically
clarify that abortion would not be covered as a future preventive care
service. I appreciate the assurances from Senator Mikulski in a
colloquy on the floor that abortion would not be covered as a
preventive service, but words do not supersede the language in the
legislative text. I do

[[Page S12278]]

look forward to ways in which Congress can further preventive care
services for women.
The PRESIDING OFFICER. The Senator from Colorado is recognized.

Amendment No. 2826 to Amendment No. 2786

Mr. BENNET. Mr. President, I have an amendment No. 2826 at the desk.
I would like to call it up at this time.
The PRESIDING OFFICER. The clerk will report.
The assistant bill clerk read as follows:

The Senator from Colorado [Mr. Bennet], for himself, Mr.
Harkin, Mr. Dodd, Mr. Brown, Mr. Durbin, Mrs. Lincoln, Mr.
Wyden, Mr. Begich, Mr. Bayh, and Mrs. Shaheen, proposes an
amendment numbered 2826 to amendment No. 2786.

Mr. BENNET. Mr. President, I ask unanimous consent that reading of
the amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment is as follows:

(Purpose: To protect and improve guaranteed Medicare benefits)

On page 1134, between lines 3 and 4, insert the following:

Subtitle G--Protecting and Improving Guaranteed Medicare Benefits

SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE
BENEFITS.

(a) Protecting Guaranteed Medicare Benefits.--Nothing in
the provisions of, or amendments made by, this Act shall
result in a reduction of guaranteed benefits under title
XVIII of the Social Security Act.
(b) Ensuring That Medicare Savings Benefit the Medicare
Program and Medicare Beneficiaries.--Savings generated for
the Medicare program under title XVIII of the Social Security
Act under the provisions of, and amendments made by, this Act
shall extend the solvency of the Medicare trust funds, reduce
Medicare premiums and other cost-sharing for beneficiaries,
and improve or expand guaranteed Medicare benefits and
protect access to Medicare providers.

Mr. BENNET. Mr. President, I was paying very close attention to the
floor debate over the last few days, and at times I am beginning to
wonder what bill it is we are debating. Only in Washington could an
effort to extend the life of the Medicare trust fund be viewed or
distorted somehow as being unfair or bad for seniors.
We know--and it is in print in the CBO report--this bill doesn't take
away any senior's guaranteed Medicare benefits. We know the bill
extends Medicare solvency for 5 additional years. How does it do that?
It does it in a way that is different from the way government usually
does business, which is either adding or cutting from a program. It
changes the way we deliver medicine in this country, and it does it in
a way that protects senior benefits, and it extends the life of
Medicare.
The attacks on this bill and my amendment have nothing to do with
those facts. The sad part is that there are ideas on every side of this
debate that are worth considering. We should be debating those ideas
rather than claiming something that is just not true about the bill.
These Washington tactics of trying to shift health care reform back
to some committee to languish is exactly why nothing ever gets done
around here. The almost unbelievable part of this is that the opponents
of my amendment say the health care bill hurts seniors. Yet the bill
and our amendment is being supported by the AARP, the Alliance for
Retired Americans, Center for Medicare Rights, and the National
Committee to Preserve Social Security and Medicare.
What are the opponents of my amendment actually saying--that AARP and
other senior advocates don't know what they are doing? They know what
they are doing, and they also know what is in the bill. The AARP has
seniors' best interests in mind, and they want what is best for
Medicare in the long run. This bill makes tremendous strides to a more
solvent, more stable Medicare Program for years to come.
Unfortunately, in the hopes of eventually trying to kill the bill,
there are people who are making claims that are frightening our
seniors--meant to frighten them--here and also in Colorado, where
people have been calling on their phones convinced that somehow I want
to cut their benefits. Nothing could be further from the truth. I
believe strongly in the sacred trust we have created with our seniors.
That is why I introduced this amendment. Seniors are looking for simple
clarity, and health care reform can help their lives.
This amendment says, in the clearest and most unambiguous of terms,
as directly as we can say it, that nothing in this bill will cut
guaranteed Medicare benefits. All guaranteed Medicare benefits stay
intact for every senior in Colorado and all across the country. Seniors
will still have access to hospital stays, to doctors, home health care,
nursing homes, and prescription drugs.
The second part of the amendment goes further and says clearly and
directly to seniors that we will use this bill to further protect and
strengthen Medicare. We will extend the life of the Medicare trust
fund. We will lower premiums or cost share, increase Medicare benefits,
and improve access to providers. You don't need to believe me. Look at
the CBO. These improvements will be paid for with money saved in
Medicare under this bill.
What is so regrettable about the debate, and so tragic, is, if we
don't actually get this done, Medicare would be bankrupt in just 7
years--in 2017. In the Senate bill we are now considering, we extend
the trust fund's solvency by 5 years. We lower premiums for seniors by
$30 billion over 10 years. That is real money back in the pockets of
our seniors. We eliminate copays that seniors now have to pay for
preventive care. That means when seniors go to the doctor for a
colonoscopy, they would not have to make the copay like they have to
under current law. When they go to get a mammogram, the same is true.
We know preventive care like that saves lives and also money.
Most seniors live on a fixed income. Free preventive care is the best
way to encourage seniors to seek important medical precautions. More
preventive care is proven to save lives and lower health care costs.
Mr. President, health care reform will cut the cost of brand-name
prescription drugs in half for those who are stuck in the gap of
coverage between initial and catastrophic coverage. We eliminate the
20-percent cut physicians would otherwise see next year, making sure
seniors can continue to see their own doctor.
Opponents of health care reform don't have a plan to protect seniors
and strengthen the Medicare Program. I have heard more criticism about
the number of pages in the bill than I have heard about a responsible
alternative that would extend the life of Medicare and make the other
benefits that are in this bill.
I wanted to come to the floor with a simple and straightforward
message to seniors: We will protect Medicare. This bill does. We will
make sure nobody touches your guaranteed benefits. This bill does. We
will make sure Medicare is around for future generations. This bill
gets us started in that direction. That is why I have introduced this
amendment and why I support health care reform.
Everything I have said today is entirely consistent with the findings
of the CBO, the nonpartisan organization that advises this Chamber.
This legislation makes explicit the commitment that all of us share to
the seniors across the United States of America. It is my hope that
once this amendment passes, we can get beyond the debate we have had
over the last 72 hours and get on to the substantive aspects of the
bill.
I urge support for my amendment. I yield the floor.
The PRESIDING OFFICER. The Senator from Ohio is recognized.
Mr. VOINOVICH. Mr. President, over the past several months I have
come to the floor on a couple of occasions to remind my colleagues and
the American people about the unsustainable fiscal crisis confronting
this country.
Our national debt has exceeded $12 trillion for the first time in
history. In fact from 2008 to 2009 alone, the Federal debt will
increase 22 percent, boosting the country's debt-to-income ratio--or
national debt as a percentage of GDP--from 70 percent last year to 86
percent this year. We have not seen this kind of debt to GDP ratio
since the Second World War 65 years ago.
The American people know that this is unsustainable, but my Senate
colleagues from on the other side of the aisle continue to ignore this
reality. I pledged that I would continue to cry ``the emperor has no
clothes'' until we did something to address this crisis.
I should explain. Most people know the story, ``The Emperor's New
Clothes,'' by Hans Christian Anderson.

[[Page S12279]]

In the tale, an emperor goes about the land wearing a nonexistent
suit sold to him by a new tailor who convinced the monarch the suit is
made of the finest silks. The tailors--two swindlers--tell the emperor
that the threads of his robes will be so fine that they will look
invisible to those dimwitted, or unfit for their position. The emperor
and his ministers, themselves unable to see the clothing, lavish the
tailor with praise for the suit, because they do not want to appear
dimwitted or incompetent.
Word spread across the kingdom of the emperor's beautiful new robes.
To show off the extraordinary suit, a parade was formed. People lined
the streets to see the emperor show off his new clothes. In this case,
the health care reform bill before the Senate.
Again, afraid to appear stupid or unfit, everyone pretends to see the
suit. It is only when a child cries out ``the emperor wears no
clothes'' does the crowd acknowledge that the emperor is, in fact,
naked.
Like the little boy crying out, those of us on this side of the aisle
are pointing out this bill is fiscally not responsible.
Yet, while not addressing our current health care challenges, the so-
called health care reform bill we are debating also creates new
programs at a time when we aren't paying for the one we already have,
and it adds $2.5 trillion to what we are already spending.
I learned as a mayor and as a Governor, if you cannot afford what you
are doing, how can you take on new responsibilities?
We could be using this opportunity to fix our health care system by
finally working to lower health care costs and pass those savings on to
citizens who are already overburdened by an expensive health care
system.
Yet instead of commonsense incremental reforms that increase access
to affordable, quality health care, reduce the costs of health care for
all Americans, and lower our national health care spending, we have
this bill before us.
Unfortunately, the bill violates the medical principle, first, do no
harm. Instead, it is more of the same--more spending and more taxes--on
an already struggling economy, this at a time when we are currently
witnessing the worst recession this country has experienced since the
Great Depression.
The legislation we are considering when fully implemented, as I
pointed out, spends $2.5 trillion to restructure our health care
system. Yet it fails to rein in the cost of health spending in the next
decade. According to the Congressional Budget Office, the Federal
Government's commitment to health care; that is, the cost of health
care paid for by the Federal Government, would actually increase. In
other words, we are adding more on to this extraordinary debt we have--
unfunded mandates we have--in terms of Medicare.
The bill's proponents will tell you it is paid for. But as David
Broder points out in his November 22 Washington Post editorial:

While CBO said that both the House-passed bill and the one
Reid has drafted meet Obama's test by being budget neutral,
every expert I have talked to says the public has it right.
These bills, as they stand, are budget-busters.

And that is what many people are hearing right now from their
constituents, particularly many of those individuals who are taking
advantage of the Medicare Advantage Program.
Furthermore, as former CBO Director Douglas Holtz-Eakin pointed out
in the Wall Street Journal, this bill uses ``every budget gimmick and
trick in the books.''
What are these gimmicks? Most troubling to me and what my colleagues
on the floor have been discussing for the last few days is what the
bill does to the Medicare Program.
I think we need to be honest with the American people. The Medicare
Program is already on shaky footing. Despite $37 trillion in unfunded--
unfunded--future Medicare costs and the prediction that the Medicare
trust fund is expected to be insolvent by 2017, this bill calls for
$465 billion in cuts to Medicare, not to fix the program but, as I
said, to create new programs.
For example, this health care bill fails to acknowledge the $250
billion that is necessary to reform the Medicare physician payment
formula to ensure that our Nation's seniors will be able to see the
doctor of their choice in the future. I have heard it firsthand from
family and friends that in some places in Ohio, Medicare beneficiaries
already face delays for physician services.
Right in my hometown, I have had doctors tell me: George, if I have
somebody before they are Medicare eligible and they go on Medicare, I
will take care of them. I am not taking anymore new Medicare patients
because of the reimbursement system. I heard the same thing in terms of
Medicaid.
We have a problem out there. Sadly, my friends on the other side of
the aisle do not want to be honest with the American people and include
the cost of the physician payment fix in the bill. It should be there.
Let's be honest about it. Let's be transparent. It is another example,
I think, of the smoke and mirrors and budget gimmicks and tricks that
former CBO Director Douglas Holtz-Eakin mentioned.
Like I said, we must fix our health care system to help millions of
Americans who find themselves without insurance and those struggling to
pay their health insurance premiums. We must increase competition in
the private market, make it easier for small businesses and individuals
to purchase insurance and reform our medical liability system. I call
this malpractice lawsuit abuse reform. We should have done that a long
time ago. But the fact is that the trial lawyers do not want that to
happen. So we are doing nothing about a problem that is causing
physicians to give unnecessary tests that are driving up the cost of
health care in this country.
Most important, we need to focus our efforts on jobs, jobs, jobs,
jobs, jobs because one of the best things we can do to increase health
care coverage is to help businesses start to hire again. I need a job.
One of the reasons I need a job is when I have a job, in most
instances, I have some form of health care. We have a lot of people who
are being dropped off. We need more jobs. We should be concentrating on
that if we want to up the number of people who can get health care.
To repeat, we do not need to create another set of government
programs that spends an additional $2.5 trillion to build a new
entitlement system when we cannot afford the one we have now. That is
the biggest thing with me. If you cannot afford what you have, how can
you take on more? When we do that, we are being fiscally irresponsible.
We should deal with what we have. It is amazing to me. If you look
around the country, States are cutting their expenses and they are
raising taxes. And what are we doing in Washington? We are taking on
more expensive programs we cannot afford. That is what I think is
troublesome to me as a debt hawk.
We need to understand what we are doing. The American people are
paying attention and they know that the emperor has no clothes when it
comes to doing something about our unsustainable fiscal crisis.
We are losing our credibility and our credit worldwide. They know it
is immoral to be putting this debt on the backs of our children and
grandchildren. I believe this health care bill does that exactly. It
exacerbates our current fiscal situation.
There are lots of good things out there, a lot of good things we all
would like to do. But just like a family, if you cannot afford what you
are doing now, how can you afford to take on more responsibility in
terms of debt?
Mr. President, I yield the floor.
The PRESIDING OFFICER. The Senator from Rhode Island.
Mr. REED. Mr. President, I think it is important to focus on the
fiscal difficulties we have today, but I think it is also important to
recognize the probable causes of these huge deficits: two wars,
unfunded, no attempt to fund them, spent simply by running up the
deficit; tax cuts, which were unfunded and which did not ultimately
generate the kind of sustained economic growth and job growth that
their supporters advertised, and then the Medicare Part D program, an
entitlement program which was also completely unpaid for.
Today we have people talking about entitlement reform, how that is a
key aspect of health reform. But so many of my colleagues on the
Republican side supported President Bush when he

[[Page S12280]]

proposed the Medicare Part D program, a worthy program in concept, but
in the context of not paying for it, it is a concept that is costing us
greatly today.
Additionally, it is particularly ironic at this moment, because we
are considering a McCain motion that would report this health care bill
back to the committee with the instructions to restore $400 billion in
spending, roughly, over 10 years. I cannot think of anything more
contrary to the notion of entitlement reform.
What we have tried to do in this bill is to restructure Medicare so
that it will continue providing quality health care, but also recognize
the high costs we are facing going forward and the general economic
climate we face today. Again, let me remind you, in January 2001, the
unemployment rate was about 4.6 percent. When President Obama took
office, it was double that and growing and continuing to grow.
We have seen some effects to limit this growth, but it is still a
critical issue. Again, this reform package is designed not only to deal
with the quality of health care, accessibility to health care, and
affordability of health care, but it is designed to, over the long
term, begin to rein in costs that are absolutely out of control.
Those suffering the most from this course are the American people
and, in some respects, small business men and women. Their health care
costs are going up faster than any other costs, and in many instances
faster than wages, and it is unsustainable.

If in my State of Rhode Island we do not take effective action, we
will see within several years premiums reaching $24,000 to $30,000 a
year for a family of four. We cannot sustain that.
If someone is interested in taking the very difficult step of
entitlement reform, they would reject the McCain motion. But there are
other reasons to reject the amendment, as well. First, the funding that
has been eliminated from the current health care system and the system
going forward, has been eliminated because it does not improve care.
This is particularly true in Medicare Advantage.
This was a program that was developed and sold essentially to the
American people as cost containment for Medicare. This was one of the
proposals that would rein in out-of-control health care costs by giving
insurance companies the ability to manage more effectively.
Of course, what we have seen is a significant increase in payments to
Medicare Advantage payments over traditional Medicare. Of course, these
insurance companies can manage health care very well as long as they
are receiving very significant premium payments from beneficiaries.
But, those premiums do not essentially go to better health care. It
certainly goes, however, to better profits for the insurance companies.
Indeed, with Medicare Advantage there is a rebate given to each
insurance company. This is not the case with traditional Medicare. The
rebate was designed essentially to provide, again, lower cost access to
health care benefits for the consumers of Medicare Advantage.
The GAO found that 19 percent of Medicare Advantage beneficiaries
actually pay more than traditional Medicare for home health care and 16
percent pay more for inpatient services. Here is the irony. We are
paying the insurance companies more, but the beneficiaries of Medicare
Advantage are, indeed, are also paying more. So there is no cost
savings in this regard, in this program at least.
The other point, which is I think critical and I alluded to, is that
for the same services you receive in Medicare Advantage, there is, on
average, a 14-percent increase overall for those similar services in
traditional Medicare.
We have to, I think, take tough steps to eliminate these over-
payments, but steps that will enhance the quality of care for seniors,
and that is what is being done in this bill. While some of these
resources are being used to help redesign a system for all Americans,
there will also be significant improvements for seniors, for care that
is more effective and efficient, and less costly.
Let me suggest something else. We are all paying right now for the
cost of uninsured Americans. It has been estimated that every private
insurance plan in this country is paying--every individual payer,
businesses or individual--about $1,000 a year for uncompensated care.
That is the cost hospitals shift from their uncompensated care on to
the insurance providers, the carriers, and that is translated into
higher premiums for all Americans.
Under this legislation, the hospitals will now see patients
presenting themselves with an insurance card. Mr. President, over 94
percent of Americans, it has been estimated, will be covered under our
proposal. So instead of showing up for free care, they will be under an
insurance plan. The hospitals will benefit. Medicare, Medicaid, and the
whole health care system will benefit.
Again, this is one of the changes that would be reversed by the
McCain motion.
Also, we have taken steps so that hospitals will be much more
effective in managing their patient flow. Readmissions will hopefully
be reduced by some of the provisions in this legislation.
There are many things we should do and will do, but I believe we can
successfully balance expanding our coverage system, protecting quality
of care, but also recognizing, as has been suggested, the fiscal
implications not just for the moment but going forward. I suggest if
someone is serious about entitlement control, serious about the fiscal
implications of this legislation or any other legislation, they will
not simply order the committee to restore these cuts. They would do
something much more proactive and, indeed, support what I believe are
sensible, sound proposals to provide quality, to ensure that over the
long run, Medicare is more solvent.
In fact--the final point--the legislation before us would extend the
life of Medicare, the solvency of Medicare over at least 5 years. So
for those people who say we are trying to end Medicare, their solution
is simply to let it go bankrupt apparently in 2017 or to simply ignore
it and let it find its own fate.
We can do better. I urge rejection of the McCain motion. I yield the
floor.
The PRESIDING OFFICER (Mr. Udall of New Mexico). The Senator from
Wyoming is recognized.
Mr. BARRASSO. Mr. President, I come to the floor also to talk about
Medicare and what I see to be significant cuts in the Medicare Program.
I practiced medicine in Wyoming for 25 years, taking care of families
from across the State and many of these wonderful folks who are on
Medicare. They depend on Medicare for their health care. They depend on
Medicare. Patients depend on it, the hospitals depend upon it, the
physicians, the nursing homes, the home health care agencies--all of
them depend on Medicare for their health care.
I listened to my close friends from across the aisle come to the
floor as well, and they seem to be trying to convince the American
public that the 2,074-page bill which weighs over 20 pounds actually
does not cut Medicare. I heard the chairman of the Finance Committee
talk about it on the floor; I have heard it from the majority leader.

The health care reform plan we are looking at on this floor cuts $464
billion from Medicare, and I have a list of all the Medicare cuts in
this bill, page after page, column after column. When you add them all
up, it cuts $135 billion from our hospitals--from our hospitals--that
are providing the care. We have heard about some of the cost shifting
from the Senator from Rhode Island. Cost shifting occurs. Medicare is
one of the biggest deadbeats when it comes to paying for hospital
services, and it is why hospitals end up shifting more costs to people
who have health insurance, and why, for those people, their premiums
will go up if this bill becomes law. So $135 billion cut from
hospitals.
The bill cuts $120 billion from a program called Medicare Advantage.
There are 11 million Americans in this country who are on Medicare
Advantage. They know who they are. They know it is a program that has
worked well for them. People ask me what the difference is. Why would
somebody want to be on a program called Medicare Advantage? Well, there
is an advantage to those seniors who depend upon Medicare for their
health care if they are on Medicare Advantage. The No. 1 advantage is,
it actually helps coordinate care.

[[Page S12281]]

We know one of the best ways to help people keep down the cost of
their medical care is to find problems early and to get early
treatment. So find the problem and treat it before it gets too bad.
Well, Medicare Advantage does both preventive care as well as
coordinated care. One of the big problems with Medicare is, it will pay
a lot for doing something to someone, but it will not pay much for
helping someone stay healthy. But now all of a sudden we are going to
cut $120 billion from Medicare Advantage, which actually works on
prevention and on coordinated care.
Then there is $42 billion from home health care agencies that will be
cut. Those are the folks who come into someone's home and help them
stay out of the hospital. The advantage of home health care is to allow
people to get care at home and not need to be in the hospital, but
suddenly we are looking at $42 billion in cuts on Medicare for home
health care agencies.
Then let's take a look at nursing homes: $15 billion in cuts for
nursing homes--those facilities taking care of people on Medicare--
which, to me, means they are actually cutting it from the people who
depend on Medicare for their nursing home needs.
As an orthopedic surgeon, I have taken care of many people, such as a
grandmother who breaks her hip. She doesn't need to go into a nursing
home permanently, but what she needs to do is to go there for a short
period of time for rehabilitation, where she can get better and get
stronger. She is not ready to go home, and she does not need to stay in
a hospital, but she needs to be in a nursing home for a period of time
to get rehabilitated and then to get ready to go home and go back to an
independent life. There is a gap in time, and nursing homes help with
that. They are wonderful as a way to give somebody an opportunity to
gain their strength. In our country, such as it is now, so many
grandparents are living in communities where, perhaps, their children
or grandchildren are no longer living or they can't go and live with a
son or daughter, but they need additional help and so they go to a
nursing home.
So for that patient who has broken a hip--the type of patient I have
taken care of in the hospital--this bill is going to end up cutting
from the hospital $135 billion from Medicare for that patient. It will
end up cutting nursing homes by $15 billion, for patients who rely on
nursing homes as they recover from their hip surgery. Then once they
get home and get ready for an independent life, a lot of times they can
benefit from home health care--someone coming into the home and
checking on them, giving them medications, making sure they are doing
all right, checking their wound, and a number of different things--this
bill will cut $42 billion from home health care agencies; again,
cutting the services to people who depend upon those services for their
health care needs.
Then there is an $8 billion cut from hospice providers, people who
take care of our patients--my patients--in the final stages of their
life. At a time in their life when their body may be riddled with
cancer or they just need a place to go and be treated with respect and
to be cared for, we are cutting $8 billion in this bill from the
hospice providers--people who are there and helping people in the final
stages of their life.
When I look at this, I say: How in the world can my colleagues on the
other side say they are not cutting Medicare for our seniors? I read
through the bill and there is $135 billion from hospitals, $120 billion
from Medicare Advantage, $40 billion from home health care agencies,
almost $15 billion from nursing homes, and $8 billion from hospice
providers, for a total of $464 billion for this country's seniors. I
don't think we should pass this bill. Of course, there is another $500
billion in taxes. It is a huge and hugely expensive bill.
To me, this is absolutely nothing but robbing our folks who are on
Medicare to start a whole new government program. I am worried seniors
all around the country are going to have less access to doctors,
especially in rural and in frontier States, such as Wyoming. I am
concerned they are going to see community hospitals and home health
care agencies and nursing homes--skilled nursing facilities--struggling
to keep their doors open.
It is time for this Congress, for this Senate to listen to America's
seniors. Let's listen to the administration's own chief actuary.
Richard Foster, the chief actuary for the Centers for Medicare and
Medicaid Services, said if these Medicare cuts take effect, then many
providers ``could find it difficult to remain profitable and might end
their participation in the program.'' They may say: I don't want
anything else to do with Medicare. I am closing my doors to Medicare
patients.
We cannot have that in this country, but I believe that is what this
bill does. Even the nonpartisan Congressional Budget Office said these
Medicare cuts could ``reduce access to care or diminish the quality of
care.'' Is that what this Senate wants, to reduce access to care or
diminish the quality of care?
How many experts does it take to convince the majority party that
cutting Medicare to pay for a brandnew government program is
irresponsible? We all agree Medicare is going broke. The trust fund
will run out of money in the year 2017. It has more than $37 trillion
in unfunded liabilities. The Presiding Officer knows that in his State,
as well as in mine, Medicare's physician payment formula, which calls
for doctors to face a more than 40-percent cut over the next 10 years,
is a system that is broken. The Reid bill does nothing to fix this
problem. Instead, it takes $\1/2\ trillion from Medicare to create a
brandnew entitlement program. It punishes a group of people in order to
benefit another. To me, that is not reform. It will only make the
system worse.
That is why I support the motion we will be voting on today, the
McCain motion. It says we are not going to finance a new government
program on the backs of our Medicare patients, on the people who depend
upon Medicare for their health care. It instructs the Finance Committee
to write a bill that doesn't cut hospitals, that doesn't cut home
health care, that doesn't cut Medicare Advantage, and that doesn't cut
hospice for our seniors who depend upon those services. A vote for the
McCain motion gives us a chance to get this right.
I do want health care reform. I just don't want this bill. This is
the wrong prescription for our country. I don't believe we have to take
the money out of Medicare and then spend it on a brandnew entitlement
program. I go home to Wyoming every weekend--and I know other Members
go home and listen to their constituents--and what I hear from the
people in Wyoming is: Don't cut my Medicare. Don't raise my taxes.
Don't make things worse for me in this economy. I certainly can't
afford it. The people of Wyoming want practical, commonsense health
care reform; reform that drives down the cost of medical care, improves
access to providers and creates more choices.
It is clear this bill has a very different plan in mind. It is not
too late to work together for meaningful reform. We do not have to
dismantle the current health care system and build it up in the image
of big government and then try to say this is reform. The American
people are telling us what kind of changes they want, and that is why I
will be voting for the McCain motion.
I yield the floor.
The PRESIDING OFFICER. The Senator from Montana is recognized.
Mr. BAUCUS. Mr. President, I wonder if the Senator from Wyoming would
be available to answer a question.
Mr. BARRASSO. I will, Mr. President.
Mr. BAUCUS. I am thankful to my good friend and neighbor to my State.
Is it true the CBO letters say the Senate bill will extend the life--
extend the solvency of the Medicare trust fund? Is that true?
Mr. BARRASSO. I don't have that letter with me, but everything I look
at says this will gut Medicare, make it go broke sooner, and it will be
bad for seniors.
Mr. BAUCUS. I don't have the letter in front of me, but in all
deference and respect to my good friend from Wyoming, the CBO says the
exact opposite. It is the conclusion of the Congressional Budget Office
that this legislation will help seniors by extending the solvency of
the Medicare trust fund by, I guess, 4 to 5 years. That is black and
white. If I had the letter in front of me, I could read it to him, but
that is a

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fact. This legislation will extend the solvency of the Medicare trust
fund by another 5 years.
So instead of being insolvent in the year 2017, under this
legislation, that is extended to the year 2022. That is a fact. At
least the fact is that is what CBO concludes in their letter. That is a
fact.
Second, as a caring physician, does the Senator think that we as a
country should try to find a way to provide health insurance for so
many Americans--some of them lower income--who don't have health
insurance in our country? Because, after all, we are the only
industrialized country in the world that doesn't find a way to make
sure its citizens have health insurance.
As a physician who sees patients, many of whom can't pay their bills
and defer medical treatment because they do not have health insurance,
I am wondering if the Senator believes this country should try to find
a way where its citizens have health insurance.
Mr. BARRASSO. The Senator absolutely believes we need to find a way
to make sure all the citizens of this country have insurance, and there
are ways to do it: allowing people to buy insurance across State lines.
That doesn't take a 2,000-page bill. There are ways to do it to help
get down the cost of care that give individuals incentives to buy their
own insurance, giving tax breaks to those individuals. We could do
things with tort reform, such as the loser pays rule. We could allow
small groups to join together to have a better ability to bargain and
get the cost of insurance down.
So this Senator absolutely believes we need to find a way to get
everyone insured. There are people who need help who don't have help,
and we need to find a way to do that, but it is not this 2,000-page
bill.
Mr. BAUCUS. I will ask this question, and then I will finish because
I know my colleagues want to speak.
One of the basic underpinnings of this legislation is that we should
change the way we reimburse providers, moving away from quantity and
volume and more toward quality. I am curious--and this is not an
antagonistic question. I am just trying to get a physician's point of
view because so many doctors I talk to think that although it creates a
little uncertainty, probably that is the right thing to do--to move our
reimbursing based on quality, coordinated care, and focusing on the
patient rather than our current system, which reimburses more on
quantity and the number of services provided, et cetera.
Is that something the Senator thinks we should pursue in this
country?
Mr. BARRASSO. The current system is broken, Mr. President. The
reimbursement system focuses more on doing things than on helping
patients stay healthy and get better. Medicare has done a terrible job
of that over the years, in terms of giving incentives for people or
even for paying for preventive services. They have not done that over
the years.
This is an illustration of how the system is broken. It is now
December--the end of the year--and it is the busiest time of year for
me as a physician in Wyoming because people have met their
deductibles--those who have insurance have met their deductibles for
the year--and they come into the office and say: Is it now time for my
operation? I have to get it done before the 1st of the year because my
deductible has been used up, and I want to have my operation so I am
not going to have to pay for it.
In this country, we have the incentives all wrong in terms of health
care. We do need health care reform.
Mr. BAUCUS. I agree.
Mr. BARRASSO. I don't think this bill is the way to do it, which is a
government takeover of the health care system.
Mr. BAUCUS. Mr. President, I have to address that one. My colleagues
want to speak, but I think it is worth repeating over and over again:
This legislation is designed to retain the uniquely American solution
to health care--roughly half public, half private. It is designed to
make sure patients can still, as they should, choose their own doctor,
any doctor they want--primary care doc, specialist, no gatekeepers and
all that stuff. The doctors are totally free and should be free to make
their own decisions, after consultation with their patients, as to what
procedure makes sense or doesn't make sense.
In addition to that, frankly, more competition with the exchanges.
This legislation, frankly, is rooted almost entirely on maintaining the
current free market system in health care. There is some insurance
market reform, which I think everybody agrees with, which is denying
preexisting conditions as a basis for denying coverage, and there is a
modest expansion of Medicaid for lower income people who just can't get
health care, but otherwise this is legislation which is rooted in the
current American system.
We have a good system. It works. This is just designed to make it
work a little better by making sure it reimburses, as the Senator from
Wyoming wants, based more on quality. He didn't mention this, but I
know he agrees, also insurance market reform so those patients who come
to him don't have to wait until the end of the year in the future as
they have in the past.
But I want to get it very clear, this is no ``government takeover.''
That is a scare tactic. It is not accurate. It is basically maintaining
our current system.
I would now like to yield 10 minutes to my good friend from Vermont.
The PRESIDING OFFICER. The Senator from Vermont is recognized.
Mr. SANDERS. I am going to speak on something other than health care.
I thank my friend from Montana for yielding.

Confirmation of Federal Reserve Chairman

Mr. SANDERS. Mr. President, what I want to touch upon is my strong
belief that Ben Bernanke should not be reappointed for a second term as
Chairman of the Federal Reserve. In that regard, I placed a hold on his
nomination.
Everyone in this country understands we are in the midst of the worst
economic crisis since the Great Depression. We are looking at 17
percent of our people being either unemployed or underemployed. We are
looking at average length of unemployment being longer than it has been
since World War II. We are looking at a situation where, over the last
8 or 9 years, median household income has declined by over $2,000. We
are looking at a situation where, according to USA Today, September 18,
2009:

The incomes of the young and middle aged, especially men,
have fallen off a cliff since 2000, leaving many age groups
poorer than they were even in the 1970's.

What we are seeing is a long-term trend resulting in the collapse of
the middle class, an increase in poverty, a growing gap between the
rich and everybody else. Then, to make a very bad situation worse, as a
result of the greed, irresponsibility, and illegal behavior of Wall
Street, we are now in a terrible economic decline.
The American people voted overwhelmingly last year for a change in
our national policies and for a new direction in the economy. After 8
long years of trickle-down economics that benefited the very wealthy at
the expense of the middle class and working families, the people of our
country demanded a change that would put the interests of ordinary
people ahead of the greed of Wall Street and the wealthy few. What the
American people did not bargain for was another 4 years for one of the
key architects of the Bush economy, Federal Reserve Chairman Ben
Bernanke.
The Chairman of the Federal Reserve--and the Federal Reserve itself--
has four main responsibilities. I want the American people to determine
whether they believe the Fed has, in fact, succeeded in fulfilling
these obligations. Here they are, four main responsibilities:
No. 1, to conduct monetary policy in a way that leads to maximum
employment and stable prices. Maximum employment? When you have 17
percent of your people unemployed or underemployed, I do not think the
Fed or all of us, any of us, have succeeded in that area.
No. 2, to maintain the safety and soundness of financial
institutions. Obviously, that has not been the case either.
No. 3, to contain systemic risk in financial markets.
No. 4, to protect consumers against deceptive and unfair financial
products.
Not since the Great Depression has the financial system been as
unsafe,

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unsound, and unstable as it has been during Mr. Bernanke's tenure. More
than 120 banks have failed since he has been Chairman, and the list of
troubled banks has grown from 50 to over 416.
Mr. Bernanke has failed to prevent banks from issuing deceptive and
unfair financial products to consumers. Under his leadership, mortgage
lenders were allowed to issue predatory loans that they knew consumers
would be unable to repay. This risky practice was allowed to continue
long after the FBI warned, in 2004, of an epidemic in mortgage fraud.
Here is what the bottom line is. The bottom line is that the key
responsibility of the Fed is to maintain the safety and soundness of
our financial institutions, and they failed. They failed. As a result
of the greed and speculation on Wall Street--which the Fed should have
been observing, which the Fed should have acted against, which the Fed
should have warned the American people and the Congress about--they did
nothing and our financial system went over the edge.
Then, after not doing their jobs as a watchdog, not fulfilling their
obligation to protect the safety and soundness of our financial system,
the financial collapse occurred, and what happened? What the Fed did is
provide not only--not only did Congress put $700-plus billion into the
bailout, the Fed provided several trillion dollars of zero-interest
loans to large financial institutions. When I asked Chairman Bernanke
which financial institutions received these zero-interest loans, the
answer was: I am not going to tell you. Not going to tell you.
The reason Congress, against my vote, bailed out Wall Street is they
were too big to fail. Large financial institutions were too big to
fail. Since the collapse, three out of the four largest financial
institutions have become even larger. So the systemic danger for our
economy is even greater today than it was before the bailout.
The American people want a new Wall Street. They want a Wall Street
which begins to respond to the needs of small business, so we can begin
to create jobs, not just to Wall Street's outrageous executive
compensation.
Let me suggest some of the things I think a Fed Chairman should be
doing, things Mr. Bernanke is not.
No. 1, today, bailed out financial institutions are charging
consumers 25 or 30 percent interest rates on their credit cards. The
Fed has the power to stop that, to put a cap on interest rates. That is
what they should be doing.
The Fed has the power to demand that bailed-out institutions provide
loans at low interest rates to small and medium-sized businesses so we
can begin to create the kinds of jobs that are desperately needed in
this country. That is not what Mr. Bernanke has done.
The Fed has the power now to do what is taking place in the United
Kingdom, something that many economists are demanding, and that is to
start breaking up these large financial institutions which are too big
to fail. In my view, if an institution is too big to fail, it is too
big to exist. We have to start breaking them up, not allow them to get
even larger. The Fed has chosen not to do that.
We need transparency at the Fed. I am the author of a GAO audit of
the Fed, which now has 30 cosponsors, which I hope we will pass. But at
the very least, if the taxpayers of this country are putting at risk
trillions of dollars being lent out to large financial institutions, we
have a right to know which institutions are receiving that money and
under what terms.
Let me conclude by saying this: This country is in the midst of a
horrendous economic crisis. Millions of families all over this country
are at their wit's end. They are suffering. They are trying to figure
out how they are going to keep warm this winter, how they are going to
pay their bills. The time is now for a new Fed, for a new direction on
Wall Street, for a Wall Street which is helping our productive economy
create decent-paying jobs, not a Wall Street based on greed, only for
themselves, whose goal in life is to make as much money as possible for
their CEOs.
We need a new Fed, we need a new Wall Street, and we surely need a
new Chairman of the Fed. My hope is that President Obama will give us a
new nominee and not Mr. Bernanke.
I yield the floor.
The PRESIDING OFFICER. Who yields time? The Senator from Montana.
Mr. BAUCUS. Mr. President, I ask how much time is remaining on each
side?
The PRESIDING OFFICER. On the majority side, 9 minutes 20 seconds; on
the minority side, 23 minutes 10 seconds.
Mr. BAUCUS. Mr. President, I yield 9 minutes--how many seconds?
The PRESIDING OFFICER. Now 9 minutes 11 seconds.
Mr. BAUCUS. I yield 9 minutes 11 seconds to the Senator from Iowa.
The PRESIDING OFFICER. The Senator from Iowa is recognized.
Mr. HARKIN. I am deeply saddened that my Republican colleagues have,
now we see very clearly, resorted to fear tactics in their desperate
attempt to preserve a dysfunctional, costly, status quo medical system
that we have in this country today. Republicans, in their attempt to
strike fear in seniors across the country, are trying to convince the
people that they have changed from the party that has always opposed
Medicare to now being Medicare's staunchest defenders. But we all know,
if it were up to our friends on the other side of the aisle, there
would be no Medicare. They fought its very creation. Don't take my word
for it, take one of their standard-bearers who ran for President.
Senator Bob Dole, who was here when we created Medicare, Senator Dole,
a friend of mine--I have a good deal of admiration for Senator Dole--
said, ``I was there, fighting the fight, voting against Medicare--one
of twelve--because we knew it wouldn't work in 1965.'' He said that in
1995 when he was running for President. He was proud of the fact that
he and Republicans had opposed the establishment of the Medicare
system.
You might say: That was then, what about recently? Here is the former
Speaker of the House, Newt Gingrich. He said, ``We believe it's going
to wither on the vine,'' speaking of Medicare.
Now my friends on the other side of the aisle--listening to them, you
would think they were the biggest supporters of Medicare forever, when
they opposed it from its very beginning.
Now we hear all the stuff about Medicare Advantage. If, in fact, we
are going to be cutting a little bit out of Medicare Advantage, they
would like to tell you that somehow this is going to ruin Medicare. If
that were true, why would the National Committee to Preserve Social
Security and Medicare, AARP, the alliance for retired Americans, groups
that represent tens of millions of seniors--why would they stand with
us in support of our bill and not with the Republicans, who want to gut
the very provisions we have in there that will strengthen and preserve
Medicare?
Do people really believe our Republican colleagues care more about
seniors than these groups that actually represent seniors?
The truth is, when we talk about Medicare Advantage, we are talking
about private insurance companies who promised that through competition
they were going to deliver better quality health care to seniors at a
lower cost. It all sounded good. But what has happened since Medicare
Advantage has come in? The reality is, Medicare is now paying on
average 14 percent more to these private plans than it would cost to
cover the same beneficiaries under traditional Medicare. In some cases,
it is as high as 50 percent more. That is $12 billion a year more than
if these beneficiaries stayed in Medicare. Basically, we are giving a
$12 billion subsidy to these companies.
Again, don't take my word for it. This is from a June 2009 MedPAC
report:

We estimate that in 2009, Medicare paid about $12 billion
more for enrollees of [Medicare Advantage] plans than it
would if they were in [fee-for-service] Medicare.

A $12 billion slush fund. We are saying we are going to reduce some
of those subsidies. I hear my friends on the other side: My gosh,
Medicare is going to take away all these benefits, and all that other
kind of stuff. Not necessarily. Right now we know, according to CBO,
our bill will lower seniors' Medicare premiums by $30 billion over 10
years.
Then the other side says: But if you cut these Medicare Advantage
payments, you will see their benefits cut.

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That is absolutely not true. All Medicare plans, whether traditional
Medicare or private, must offer all required Medicare benefits. Here is
the kicker. If, in fact, there are some cuts made in Medicare
Advantage, then these private companies that are making $12 billion in
their slush fund, maybe rather than cutting benefits, maybe they will
decide to cut their CEO salaries from $12 million a year to $10 million
a year. Maybe they will decide instead of three or four corporate jets,
they only need one. Maybe they will start reducing some of the profits
they are making, huge profits they are making off of the taxpayers and
off of Medicare payees right now.
Again, if we cut the Medicare Advantage Program, I guess my friends
on the other side would say, No. 1, they can continue to pay their CEOs
$12 million a year salaries. They can continue the corporate jets. They
can continue to have fancy buildings. They can continue to have
outrageous profits. But they will have to cut Medicare. That is what
the other side is saying.
We are saying: No, cut the CEO salaries. Cut the enormous profits.
Cut those corporate jets. Cut all of that stuff you are using the slush
fund for, but keep the benefits for Medicare.
As I said, under present law they cannot cut the basic Medicare
benefits. No senior anywhere in America will lose their core Medicare
benefits under our bill. Let's be clear about that. If they did, AARP,
the National Committee to Preserve Social Security and Medicare, and
the National Alliance for Retired Americans would never be supporting
our bill.
Lastly, according to an economic survey done at Boston University,
they extensively analyzed Medicare Advantage payments and found that
just 14 percent of the additional funds these private plans have
received have gone to benefit Medicare enrollees. The vast majority of
the payments, 86 percent, go to profits, CEO salaries, corporate jets,
all these other things, or some of it may go to things such as gym
memberships, spa memberships. I raised the point the other day. Why
should my Medicare beneficiaries in Iowa have to pay more in Medicare
so that a Medicare beneficiary, say, in Arizona can go to a spa and
have it paid for by Medicare Advantage, paid for by the subsidies of
$12 billion that we give them that come both from taxpayers and from
Medicare recipients right now? I don't think it is fair for my seniors
in Iowa to have to pay for that.
A lot has been said about all the people who are in the Medicare
Advantage plans. I looked up the figures. Right now, nationally, only
18.6 percent of all enrollees are in Medicare Advantage, a little less
than one out of five. In my State, in Iowa, it is 10 percent, 1 out of
every 10. Why is that? We don't have a lot of spas in Iowa. We don't
have those fancy things like they have in Florida and Texas and Arizona
and California, wherever else all this stuff is going. What my seniors
need is the peace of mind of knowing that Medicare is going to be there
for them in the future. They need to know they are going to get the
benefits we have put in this plan that are in our bill and that will
help Medicare beneficiaries.
Here is what they are. AARP says:

The new Senate bill makes improvements in the Medicare
program by creating a new annual wellness benefit, providing
preventive benefits and, most notably for AARP members,
reducing drug costs for seniors who fall into the dreaded
Medicare doughnut hole.
The bill also makes improvements on age rating, a
discriminatory practice that allows insurers to charge
exorbitant age-based premiums to older Americans.
Finally, AARP strongly supports provisions in the Senate
bill to strengthen long-term services and supports. We also
applaud inclusion of provisions to improve access to Medicaid
home and community-based services.

All is in our bill, all of which would fall if we adopt the McCain
amendment. I urge colleagues not to listen to the rhetoric from the
other side. Listen to those who really do represent seniors. Make sure
we preserve and protect the basic Medicare functions for seniors and
for those who are about to retire. You will not get that through
Medicare Advantage. If Medicare Advantage wants to exist and compete on
a level playing field, God bless them. Go ahead and get it done. That
is what we were promised when Medicare Advantage came through here. I
remember. Competition. But what we found is, we had to cough up an
additional $12 billion to subsidize them.
It is time for us again to say no to the fearmongers, to those who
are trying to strike fear in seniors. It is time to stand up, support
the Bennet amendment, which makes very clear that any savings that come
from Medicare has to go back into Medicare. That is the way it ought to
be. That is what is in this bill. The Bennet amendment makes that
crystal clear. The McCain motion does away, basically, with all of the
protections, all of the things we have worked so hard for since 1965 to
provide. The McCain motion, when you strip away all the verbiage,
really what it does is, it basically takes us back to pre-1965 when we
didn't even have Medicare. That is the kind of intent behind it.
Mr. BROWN. Will the Senator yield for a question?
Mr. HARKIN. I am glad to yield.
Mr. BROWN. I thank the Senator for his incredible leadership on this
issue and the public option, affordability, and on prevention and
wellness.
I have listened to the debate with Senator McCain and others on
Medicare. It seems what they are protecting is not Medicare but the
huge insurance company subsidies when President Bush moved to privatize
Medicare. It used to be the insurance companies told us they could do
their part of Medicare, one-fifth, one-sixth of Medicare; that they
could do it more efficiently even though insurance companies have a 15-
, 20-percent administrative cost overhead and Medicare's is 3 or 4
percent or 2 percent.
The PRESIDING OFFICER. The Chair reminds the Senator, the majority
time has expired.
Mr. BROWN. I ask unanimous consent for 2 additional minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BROWN. Much of what they are trying to protect is insurance
company subsidies, not Medicare benefits which their party has opposed
for much of the last 40 years, including its creation.
Mr. HARKIN. As I said earlier, what they are talking about in
preserving these benefits and this subsidy for Medicare Advantage is
the big CEO compensation packages, the corporate jets, the fancy
buildings, the high profits, somewhere between 30 percent and 200
percent profits made by these companies that are providing Medicare
Advantage. That is what the Republicans are trying to protect, not the
Medicare recipients.
Mr. BROWN. I thank the Senator.
The PRESIDING OFFICER. The Senator from Utah is recognized.
Mr. BENNETT. Mr. President, I listened with some interest to the
comments made when I came on the Senate floor. I simply want to make
this one observation about Medicare Advantage. President Obama promised
that Americans who have coverage they like would not lose the coverage
they have. There are a number of Americans who have Medicare Advantage.
They like it, and they want to keep it. This Congress is about to say:
No, you can't. This Congress, through this bill, if it passes, is going
to eliminate Medicare Advantage. Frankly, the people who go after
Medicare Advantage because they like it are going to be the ones who
are disadvantaged. They are going to be the ones who will see President
Obama's pledge violated.
Frankly, I don't think they much care about how much an executive is
paid or what happens in the company. They care that they have coverage
they like, coverage they are paying for, coverage they have chosen, and
they are being told by the Federal Government they cannot have what
they want.
There is another aspect to this that I would like to explore in the
time I have. We keep hearing so much about the CBO and all of the
scores the CBO is pointing out along with rhetoric that says we can't
afford to wait, we need a solution now, the status quo is unacceptable.
I would like to point out that the status will remain quo for 4 years
if this bill passes. In the budget smoke and mirrors that have been put
into this bill in order to make it look as if it costs less money, they
make the effective date in 2014, so there will be 4 years after the
passage of this bill where Americans will not see any kind of change in
their plans. What they

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will see is an increase in their premiums. They will see an increase in
taxes.
Why do I say that? Between January of 2010 and January of 2014 there
will be four open seasons in which plans can be changed. As the taxes
start to hit, as the costs start to hit, those companies that are
involved in offering these plans will say: OK, we have to get ready for
the expenditures. What do we do? We have four open seasons in which to
change our plans before this thing hits.
Obviously, that cannot be scored by CBO because CBO does not know
what changes will be made. But do we really think we can go through
four open seasons with no change whatsoever in the face of this
enormous change that will hit in January of 2014? Do we really think
everything is going to remain static? That is what the CBO computers
are. Do we really think the $500 billion they want to take out of
Medicare to help pay for this will not be hashed over again and again?
One of two things will happen. No. 1, the Democrats will blink in the
face of the anger of senior citizens and say: We really didn't mean it.
Yes, the bill cuts Medicare by $500 billion, but we really didn't mean
it. We have 4 years in which to fix it; that is, 4 years in which to
replace that $500 billion. Of course, when that $500 billion is
replaced, if that is the way they decide to go, then we will know that
the numbers we are getting out of CBO are completely phony. Then we
will know the statement that this bill is revenue neutral is a
nonstarter. Then we will know there was never any intention to try to
deal with this cost.
Suppose future Congresses stand firm and say: Yes, we are going to
stand firm in this 4-year period. We are going to stand firm against
the anger of senior citizens who are seeing their Medicare benefits get
cut. We are going to take the $500 billion out of Medicare. Then we
will see the promises that are being made around here--that there will
be no cut in Medicare services--all disappear.

I hear people say: We are not cutting benefits. We are just cutting
payments to providers. That statement is being made over and over again
on the other side of the aisle: We are not cutting benefits. We are
going to take that $500 billion away from the providers, but the
benefits will remain the same.
In my State, I have plenty of providers that are on the edge, right
now, financially. They are on the edge of going out of business, right
now, financially because of the cuts that have been made in Medicare in
the name of cutting down payments to providers.
What happens to the people who are in a nursing home that is
currently dependent upon Medicare payments in order to survive if they
come in and say: All right, we are not going to do anything to the
benefits these people are entitled to in this nursing home, we are just
going to cut enough payments to the nursing home that the nursing home
goes out of business. What happens to the people who are in the nursing
home under that circumstance? Well, they are going to have to go
someplace else and there is going to have to be money to pay for them
to go someplace else and the money is going to have to flow through
Medicare someplace else and then we are back to the first option I
talked about, which is we were not serious when we said we were going
to take $500 billion out of Medicare. We were not serious. In order to
make sure you do not lose your benefits, we are going to have to start
reinvesting in some of these providers. We have seen providers go out
of business because of the cuts into Medicare. We need to start putting
that money back into Medicare. Then we are back into the circumstance
we have been talking about all along: This thing is not paid for.
One final point I wish to make: We had a hearing today with the
Chairman of the Federal Reserve. Ben Bernanke is up for reappointment
and, of course, the entire conversation was about the economy and what
is the future of the economy. There were a number of people who had a
conversation about the past, but I wished to focus on the future.
I pointed this out to the Chairman and asked for his comments with
respect to the future of our economy. Most of my constituents do not
understand what I am about to say. Frankly, most of the people in the
press do not understand it, and maybe even some Members of this body do
not understand it. When we talk about the Federal budget, two-thirds of
the Federal budget is beyond the control of this Congress. Two-thirds
of the Federal budget is on autopilot, unless this Congress changes
entitlements.
Somebody says: Well, what does this word ``entitlement'' mean? Why do
you talk about entitlements? Entitlement means, by law, these
individuals are entitled to this money, whether we have it or not. The
Federal Government has made a contract with them. All right, it is a
social contract rather than a legal contract, but it is as binding
politically where the Federal Government has to spend the money,
whether it has it or not.
Indeed, that is what we have seen in fiscal year 2010. The budget we
passed said revenues are going to be $2.2 trillion and entitlement
spending is going to be $2.2 trillion, which means every function of
the government--our Embassies overseas; our troops, wherever they may
be; education; national parks; whatever it is--every dime will have to
be borrowed in fiscal year 2010, every single dime because every penny
coming into the Federal Government is already programmed to go out,
without coming through the Congress. It does not go through the
appropriations process. We do not get to vote on it. People are
entitled to receive this money, and it is going to go out there.
What are we talking about? We are talking about creating a new
entitlement, a very expensive new entitlement. How are we going to pay
for it? According to this bill, we are going to pay for it by
transferring money from an existing entitlement. Anyone who thinks that
is what is going to happen, in the face of the anger that is being
generated by people who read about this, believes a fairytale.
The whole notion of trying to balance the cost of this tremendous new
entitlement by somehow a bookkeeping entry that says we will take it
out of the Medicare account and we will put it in this account, and the
computers that do not think--the computers simply compute--will say:
Well, then, if you put it in this account, then this account is revenue
neutral. But the government's account is not revenue neutral. This
thing is going to cost $500 billion, wherever we get the money. It is a
cynical ploy, smoke and mirrors of the worst kind, in a budgetary bait
and switch, to say we are going to take this out of Medicare.
I hear from my constituents--I hear from people who are not my
constituents who recognize me as a Senator in airports and other
places--as they say, increasingly: Do not pass this bill. We see it in
the polls, but we see it in the passion of the people who come up to us
and let us know how firmly they are opposed to this bill. The American
people do not want it, and the American people are right.
I yield the floor.
The PRESIDING OFFICER. The Senator from Iowa is recognized.
Mr. GRASSLEY. Mr. President, I would like to also make a statement
related to the amendment that is being presented by the Senator from
Colorado. Speaking for several Members on my side--hopefully, for all
the Members on my side--we are very concerned, as I think we have all
made clear by now, that the Medicare savings in this bill are being
used not for preserving Medicare but, instead, are being used to
finance the creation of a new Federal entitlement program.
My understanding of the purpose of the amendment of the Senator from
Colorado is to indicate that Medicare savings will be used for
extending the solvency of Medicare and the trust fund, reducing
Medicare premiums and other cost sharing for beneficiaries, and to
improve or expand Medicare benefits and access to providers.
Nobody can argue with that purpose the Senator has expressed or his
amendment expresses. But the concern on our side that we have with this
amendment is it does not require that the savings from Medicare would
only--with emphasis upon the word ``only''--be used for that purpose.
As the Congressional Budget Office has made clear, the cuts in
Medicare in this bill are not being used solely for Medicare, as the
Senator's amendment suggests, but, instead, are being used

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mostly to fund the creation of an entirely new and separate subsidy
program. For the Senator to accomplish what he intends to accomplish
would require entirely different language to ensure that savings from
Medicare in this bill would only be used to protect Medicare benefits
for seniors, as the law now expresses.
The right approach would include language making sure seniors have
the same access as they have today, to home health services, skilled
nursing facilities and services, hospice care, hospital services,
preventive benefits, and the benefits provided in the Medicare
Advantage Program. So the Senate, it seems to me, should also ensure
that Medicare savings in this bill are not being siphoned off to
finance a new and separate entitlement program.
It is very clear to me--and I hope we are able to make it clear to
people, all 100 Senators--that the Bennet amendment, as written, does
not protect Medicare.
I yield the floor.
The PRESIDING OFFICER. Who yields time?
Mr. BAUCUS. Mr. President, I do not think I have any time, but I ask
unanimous consent that as to the time I do have after 2 o'clock, I can
take 2 minutes of that so I can ask a question of my good friend from
Iowa.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BAUCUS. Mr. President, I might ask my friend from Iowa, Senator
Grassley, a question, if he is available for a question. I am taking
time.
Mr. GRASSLEY. Mr. President, I will take a short minute to respond to
a question. But our side has 7--
Mr. BAUCUS. I understand. I do not want to cut into that time at all.
Mr. GRASSLEY. Could we discuss this maybe a little bit later, what
you brought up?
Mr. BAUCUS. I am taking it off my time, not your time.
Mr. GRASSLEY. OK.
Mr. BAUCUS. Is it true the Congressional Budget Office said this
bill, over 10 years, is not only deficit neutral but actually decreases
the budget deficit by about $130 billion? Is that true? Is that what
the Congressional Budget Office said?
Mr. GRASSLEY. That is true. But I do not think the Senator wants to
go down that road because, do not forget, there are 6 years of
programs, of expenditures, and there is 10 years of revenue coming in.
If you want to play that game, you can pay down the entire national
debt.
Mr. BAUCUS. Well, I do not know--to be totally fair and respectful to
one of my very best friends in the Senate--to cover that point, isn't
it also true the Congressional Budget Office said in the second 10
years this bill will reduce the budget by one-quarter percent of GDP?
Isn't that also true, according to the Congressional Budget Office?
Mr. GRASSLEY. I cannot respond to that because I do not know that for
sure. So I do not want to respond. But if you tell me, I tend to
believe everything you tell me.
Mr. BAUCUS. We trust each other. We both trust each other. That is
what the letter says.
Thank you.
The PRESIDING OFFICER. The Senator from Arizona is recognized.
Mr. McCAIN. Mr. President, I ask unanimous consent that my colleagues
and I--the Senator from Tennessee, Mr. Alexander; the Senator from
Oklahoma, Mr. Coburn; Senator LeMieux from Florida; Senator Enzi; and
Senator Crapo--be allowed to engage in a colloquy.
The PRESIDING OFFICER. Is there objection?
Without objection, it is so ordered.
Mr. McCAIN. Mr. President, how much time do we have?
The PRESIDING OFFICER. The minority has 3 minutes 42 seconds; and
then, on top of that, at 2 o'clock, the Senator from Arizona controls
17\1/2\ minutes.
Mr. McCAIN. Thank you. I will let those minutes run together, if
there is no objection.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. McCAIN. Mr. President, I wish to begin our conversation with a
brief comment about the American Association of Retired Persons, known
as the AARP, that has now come out against this amendment, incredibly.
It is a fascinating history of that liberal Democratic group because,
in 1993, when we had some savings in Medicare, the AARP said:

If we're talking about Medicare cuts alone as a way of
financing health reform, we would fight that with all our
strength--we've gone as far as we can go down that road.

The AARP, on $6.4 billion Medicare cuts in 2005, said: ``Strongly
Opposes.'' They said the:

. . . conference agreement . . . undermines the critical
protections built into both the Medicaid and Medicare
programs. Instead of . . . shared sacrifice to achieve
budgetary savings. . . .

Every time there has ever been a savings in Medicare or Social
Security in any way, shape, or form, the AARP has come out against it,
except now when there is the most massive cut in Medicare in history
and a transfer of those funds to a vast new $2.5 trillion entitlement
program. It was described as $2.5 trillion just yesterday by the
chairman of the Finance Committee.
I say shame on the AARP. I say to my friends, especially those who
are under the Medicare Advantage Program, the 330,000 in my State, for
whom, admittedly, they are going to cut their Medicare Advantage
benefits, take your AARP card, cut it in half, and send it back. They
have betrayed you.
The PRESIDING OFFICER. The Senator from Oklahoma is recognized.
Mr. COBURN. Mr. President, the chart behind me shows the cuts in
Medicare that are in this bill. We have heard all sorts of arguments. I
have a few rhetorical questions for my colleagues and my friend, the
President of the United States.
There is no question Medicare Advantage costs too much. I have agreed
to that with the chairman of the Finance Committee. But you cannot say
that coordinated care does not improve the care of seniors, and that is
going to be cut. You cannot say that eyeglasses and hearing aids are
not going to be cut, and they do improve the care. You cannot say to
seniors who cannot afford a supplemental policy, who have Medicare
Advantage, they are not going to lose some of their care. They are. In
fact, 2.6 million, according to the Congressional Budget Office, are
going to lose that very care--not some of it, all of it. They are going
to lose that advantage under this legislation. The answer to the
question, will this impact seniors care, is yes. We have heard these
cuts aren't going to impact anybody or the only people they are going
to impact are the insurance companies. Well, I am all for impacting the
insurance companies, but I don't want to impact patients negatively.

So we have cuts to Medicare, including hospitals, of $134.7 billion;
hospices, $7.7 billion; nursing homes, $14.6 billion; Medicare
Advantage, $120 billion; home health agencies, $42.1 billion; and then
you say you are not going to do anything to impact the care of seniors.
My colleague from Iowa, whom I love, disputed my statement about the
fact that the life expectancy is going to go down under this bill. He
has never practiced medicine a day in his life. I know what goes on
inside hospitals. When you cut $130 billion out of the hospitals, the
time you are going to wait for me, the time you wait after you push
your call button is going to get extended and the complications from
that are going to result in decreased quality of care and shortened
life expectancies. There is no question about it.
So we can play the game, but the real thing Americans ought to know
is almost $500 billion of spending on Medicare patients today is going
to go by the wayside to be spent on a new entitlement, on a brandnew
entitlement.
The PRESIDING OFFICER (Mr. Brown). The Senator from Idaho is
recognized.
Mr. CRAPO. If the Senator from Oklahoma will respond to a question,
he is a physician, and he has very well pointed out how the cuts to
Medicare Advantage will reduce benefits to senior citizens. The impacts
on the hospitals and home health care and the skilled nursing
facilities and so forth will be reduced services. I am aware of a June
2008 report from the Medicare Payment Advisory Commission, MedPAC,
which said 29 percent of Medicare beneficiaries they surveyed who were
looking for a primary care physician had trouble finding one who would
treat them. A similar survey in Texas showed that in that State, only

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58 percent of the State's doctors would be willing to take a new
Medicare patient, and only 38 percent of the primary care doctors
accepted new patients.
So my question is, in addition to the reduction of benefits, in
addition to the reduction of access to hospitals and skilled nursing
facilities and so forth, won't these cuts and the impact on Medicare
also represent a lack of ability by Medicare recipients to literally
find physician care?
Mr. COBURN. There is no question, to answer my colleague from Idaho,
that if it doesn't eliminate the ability, it will deny by delaying the
ability. Care delayed is care denied. All you have to do is read all of
the tragedies that have gone on in this country for people who have
delayed care which has resulted in large complications for that
individual.
Mr. ENZI. Mr. President, I wish to raise a point as the accountant
around here. You have mentioned some ways to cut Medicare to pay for
this. Actually there are only two ways you can pay for a government
program. You have to do it through cuts or through taxes. I don't think
there is anybody in America who believes you can do $1 trillion worth
of new programs and have them all paid for, unless you steal somewhere.
That is what we are doing from Medicare. We say that is not going to
affect Medicare. If you eliminate the DSH payments which are part of
this, it is going to put some Wyoming hospitals out of business. I can
assure you that if those seniors can't go to a hospital in their town,
they are going to consider that a benefit cut. They are going to be
upset, and they ought to be.
The same with nursing homes. If you cut back on nursing homes, the
people who have to move to another town for a nursing home--because all
of our towns don't have more than one nursing home--puts quite a burden
not only on the patient who isn't going to get to see their family as
much, but also on the family who has to travel a long way to see the
patient. So I don't think we ought to be paying for the new programs by
doing this when Medicare needs an extended life.
I am always fascinated when they explain that this will extend the
life of Medicare because, yes, if you cut payments to everybody, that
maybe saves money and extends the life of it, if we did that. Is there
anybody who thinks we are going to cut the doctors over the next 10
years by $250 billion? No, we are not going to do that. We never have.
Mr. COBURN. Would the Senator yield for a moment?
Mr. ENZI. Yes.
Mr. COBURN. My one criticism of my colleagues in writing this bill is
I think there is money we can save in Medicare. It is called waste,
fraud, and abuse. A Harvard professor who studies this says there is at
least $125 billion a year in fraud. We have had several studies that
say it is anywhere from $100 billion to $175 billion a year. There is
nothing in this bill to eliminate fraud. What we are doing is we are
taking care from seniors instead of taking the money from the
fraudulent actors in the health care system.
Mr. ALEXANDER. Mr. President, if I may say to the Senator from
Arizona, I greatly appreciate his making this amendment, because there
is so much said here on the Senate floor that must be hard for many
people to follow. But one thing I believe everybody agrees on is there
are going to be $465 billion in cuts to Medicare over the next 10
years, period. Everybody agrees with that. The President of the United
States has said we are going to pay for this new health care bill with
one-half from Medicare cuts and one-half from taxes. Everyone agrees
with that.
What Senator McCain's amendment is saying is two things--and Senator
McCain, let me see if I characterize properly your amendment, because
it is a very simple amendment, as I read it. It is saying, send it back
to the Finance Committee and say, bring the health care bill back
without the Medicare cuts, without these cuts to hospitals, cuts to
hospices, cuts to nursing homes, cuts to Medicare Advantage, and cuts
to home health agencies.
Second, if we are going to take money from grandma's Medicare, let's
spend it on grandma. Let's take the savings we find in Medicare and
absolutely make sure we spend it on Medicare, which the trustees have
said is likely to go broke between 2015 and 2017.
Did I correctly characterize the Senator's amendment?
Mr. McCAIN. Absolutely.
Mr. ALEXANDER. And does the Senator recall a few years ago when the
Republicans suggested saving $10 billion over 5 years in Medicare, the
majority leader said that was immoral, and that other Democratic
Senators thought it was awful? If $10 billion in savings to try to make
Medicare stronger is immoral, what is spending nearly $\1/2\ trillion
on a new program called?
Mr. LeMIEUX. I wonder if I could ask a question.
The PRESIDING OFFICER. The Senator from Florida is recognized.
Mr. LeMIEUX. I have a question for my colleague from Tennessee. I am
new here. This is all new to me. I thought the goal was to reduce
health care costs while trying to provide health care for more
Americans. We are taking money out of health care for seniors to create
a new entitlement program. We are taking money out of nursing homes,
home health care, hospitals, and a program called Medicare Advantage
that people in my State I know enjoy very much. How does it make sense
that we are taking money out of Medicare to start a new health care
program?
Mr. ALEXANDER. Well, if I may say--and then I think maybe others
could respond--if you are going to spend $2.5 trillion a year, you have
to get the money from somewhere. What the Democratic health care bill
does is get it three places. One is from seniors, one is from taxes,
and one is from the grandchildren of seniors; that is, debt. It comes
from those three places.
What we heard earlier this week was the Congressional Budget Office
saying the total effect of that $2.5 trillion is that for most
Americans, premiums would continue to go up as they already are, and
that for people who go into the individual market they will go up even
more--they will go up even more--except there will be some subsidies
for a little over half of those people, and where is the subsidy money
coming from? It is coming from Medicare. So that is the answer to the
question.
Mr. LeMIEUX. It would seem to me--and again, I am new to this
process--that 100 Senators would vote for Senator McCain's proposal
because everyone in this Chamber believes we should strengthen
Medicare. Who could be for taking money out of Medicare if we don't
need to? These are two separate issues. Shouldn't every Senator in this
Chamber say let's send this back to the Finance Committee so those cuts
can be restored and we can start over and take a step-by-step approach?
That only seems fair to me.
Perhaps my colleague from Oklahoma could comment on that.
The PRESIDING OFFICER. The Senator from Oklahoma is recognized.
Mr. COBURN. I thank the Chair.
We are in trouble in Medicare in this Nation. Everybody knows it. We
have made promises. The unfunded liability on Medicare is $79 trillion.
For us to take $\1/2\ trillion, no matter what the Enron accounting
says afterward, the fact is we are going to reduce that; we are going
to make that worse. We may not make it worse next year or the year
after, but we are going to make it worse. It is going to be worse for
seniors, but it is also, as the Senator from Tennessee said, going to
be extremely worse for the seniors' kids and grandkids. Not only have
we done that, we have raised the taxes in Medicare on a certain group
of people and we are going to take that money and not put it in
Medicare; we are going to take that money, a Medicare tax, and create a
new entitlement.
So the Senator from Florida is absolutely right. If you vote against
the McCain motion you are saying you want to cut $\1/2\ trillion out of
Medicare and that it will have no effect whatsoever on the care.
I remind the Senator from Florida, there are 1 million people on
Medicare Advantage in the State of Florida, 1 million people who are
going to lose benefits under this bill. One million people in the State
of Florida will lose benefits under this bill.
Mr. ALEXANDER. Mr. President, I would ask the Senator from Oklahoma,
who is a physician himself, if one of the

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effects of cuts in Medicare is to make it more difficult for people who
are on Medicare to see a doctor. It is like giving somebody a bus
ticket and not having a bus.
I have been reading in the newspapers, for example, in the Washington
Post last month, that the Mayo Clinic, which is often held up as an
outstanding example of a clinic that keeps costs under control, has
announced it no longer will accept Medicaid patients from Nebraska and
Montana, and some Mayo clinic facilities in Arizona and in Florida are
beginning to say no more Medicare patients.
Is this what the Senator from Oklahoma thinks could be happening at
other hospitals and centers, even very good ones such as the Mayo
Clinic where they allegedly keep costs at a reasonable level?
Mr. COBURN. I think that is entirely possible. I don't know that to
be factual as of yet. What I do know is we are going to have 44 million
baby boomers in the next 12 years jump into Medicare and we are cutting
Medicare. We are going to have 44 million baby boomers jump into
Medicare. I am one of them. We are going to cut the amount of available
funds from Medicare under this bill.
Mr. ENZI. Mr. President, I wish to ask the Senator from Idaho what he
thinks will happen with these Medicare cuts as they affect jobs and the
economy. That is one of the biggest things on people's minds right now,
jobs and the economy. We are concentrating on something here where we
are going to maybe make a difference, even though CBO says it won't be
much of a difference.
Mr. CRAPO. I thank the Senator from Wyoming for that question,
because as we have already reviewed, there will be major cuts in
benefits to Medicare, to the Medicare Advantage Program. There are
going to be major reductions in access to Medicare, in terms of access
at hospitals and skilled nursing homes and facilities and home hospice
and other care.
But one of the other things we haven't focused on--and it is kind of
interesting that today is the big White House jobs summit--what is
going to happen as a result of these Medicare cuts. In addition to the
reduction of access and care and benefits to seniors, we are going to
lose jobs. I have had in my office here representatives of nursing and
home health care facilities from Idaho who have told me that if this
bill is adopted, a number of those facilities are simply going to have
to go out of business or they are going to have to dramatically reduce
the services they provide, meaning that the nurses and the other
caregivers who work there will no longer have jobs. That is part of the
way our senior citizens will lose access because there will simply be
fewer places, fewer physicians, fewer facilities that will take
Medicare patients with this kind of an attitude of the Federal
Government toward funding of Medicare.
In the end, what do we have? We have a massive expansion of
government, $2.5 trillion for a massive new entitlement program, along
with which come these incredible government controls over the economy,
as well as the creation of a new government insurance company, funded
by $\1/2\ trillion, almost, of Medicare cuts, $\1/2\ trillion in taxes,
and a massive debt, an unfunded mandate pushed on to the States.
That is one of the reasons why I think the Senator from Arizona was
so wise in bringing this motion as the first step in focusing on one of
the first fixes that needs to be made to this bill. Let's step back.
Let's not pay for a brandnew $2.5 trillion entitlement program on the
backs of our senior citizens.
Mr. ALEXANDER. How much time is left?
The PRESIDING OFFICER. The Senator from Arizona is controlling the
time, and there is 3 minutes 20 seconds remaining.
Mr. McCAIN. Mr. President, I mentioned the AARP and their opposition
to this amendment. There is an organization called 60 Plus that has
millions of supporters and members. They also feel very different from
the AARP. Their message is:

Soon you [the Senate] will vote on the McCain motion to
commit with instructions. The motion would commit it to the
Senate Committee on Finance--

Et cetera.

I and the 5.5 million supporters of 60 Plus urge you to
support this motion. The Patient Protection and Affordable
Care Act is nothing of the sort. It would cut Medicare by
$500 billion. These cuts would harm seniors who have paid
into the program and expect it to be there to help them with
their health care needs. At 60 Plus, we pride ourselves on
advocating for the best interests of seniors. That is a
``yes'' vote on this motion.

Let's pay attention to 60 Plus.
Mr. COBURN. I have a question. Does 60 Plus sell supplemental
insurance policies to seniors?
Mr. McCAIN. I don't believe so.
Mr. COBURN. But AARP does. I wonder why people want seniors off
Medicare Advantage.
Mr. McCAIN. Most people believe this would be a windfall of tens of
millions of dollars for AARP if the legislation is passed as presently
crafted.
Mr. ALEXANDER. How many Medicare Advantage members are there, for
example, in Arizona? Is it a small program or a large program?
Mr. McCAIN. Our figures are that 330,000 people in my State of
Arizona are on Medicare Advantage. I noticed yesterday, when the
distinguished chairman of the Finance Committee and the Senator from
Connecticut were talking, they were disparaging the entire program,
saying how it wasn't any good, talking about the cost overruns and
saying it was a bad program. They have opposed it from the start.
So the message to the 330,000 Americans in Arizona who are on
Medicare Advantage is that they are out to get you.
Mr. CRAPO. According to the Senator from Tennessee, it is my
understanding that nationwide it is about one-quarter of all Medicare
beneficiaries. About one in four Medicare beneficiaries in America will
see their benefits cut. All Medicare beneficiaries will see their
access cut. So these problems we are talking about are not just limited
in their impact.
Mr. McCAIN. I will respond again. There are cost problems with
Medicare Advantage, but those cost problems can be fixed. Those cost
problems can be brought under control. But the fact is, to do away with
a program that allows them a choice in how they receive their care is,
of course, again, an effort to have the government make the decisions
for people, which flies in the face of everything we stand for and
believe in.
Mr. ALEXANDER. I may say to the Senator from Arizona, I have heard
our friends on the other side say Republicans are scaring seniors about
Medicare cuts. Mr. President, it is not Republican Senators who are
scaring seniors about Medicare cuts; it is the Democratic health care
bill that is scaring seniors, because there are $\1/2\ trillion of
Medicare cuts that will pay for half of this program, and they are
outlined on this chart, as the Senators have discussed.
The PRESIDING OFFICER. The time of the Senator from Arizona has
expired. The senior Senator from Montana has 15 minutes 50 seconds.
Mr. BAUCUS. I will yield myself about 10 minutes. The Senator from
Tennessee says this is going to hurt seniors. Let's ask the senior
organizations what they think about that.
Let's also look at this organization called 60 Plus. What does the
AARP say in the letter to Senator Reid, dated December 2? It talks
about this legislation:

The legislation before the Senate properly focuses on
provider reimbursement reforms. . . .

I am sorry all my colleagues have fled the Senate. I would like for
them to stay and listen to this. I would like to hear their response.
But they have just fled the Senate after making sound bites.
Mr. ALEXANDER. Mr. President, I am here.
Mr. BAUCUS. I will take my time. The AARP letter, dated December 2,
states:

The legislation before the Senate properly focuses on
provider reimbursement reforms. . . .
Most importantly, the legislation does not reduce any
guaranteed Medicare benefits.

That is AARP. All this is scare talk about ``grandma.'' With all due
respect to my friend from Tennessee, he says that. He has been using
that phrase a lot. But AARP says that grandma is fine. AARP says:

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

It doesn't reduce any benefits, according to AARP. Going on:

[[Page S12289]]

AARP believes that savings can be found in Medicare. . . .

The savings in Medicare will extend the solvency of Medicare. I am
sure my friend from Tennessee knows the actuary said this legislation
extends the solvency of Medicare, helps Medicare. The benefits go on
longer than the status quo. Also, it does so, according to AARP, by
eliminating waste and inefficiency and aggressively rooting out fraud
and abuse. The last sentence is:

We therefore urge you to oppose the McCain amendment to
recommit. . . .

The AARP says this hurts seniors, the McCain motion to commit. I
think the job of the AARP is to figure out what is best for seniors.
That is their conclusion.
It is not just AARP's view. There is another letter. This is from the
National Committee to Preserve Social Security and Medicare. They say
basically this legislation doesn't cut Medicare benefits. Again, this
is the National Committee to Preserve Social Security and Medicare.
They say, rather, this legislation includes provisions to ensure that
seniors receive high-quality care and the best value for their Medicare
dollars. That is a very reputable senior organization. AARP is a very
reputable senior organization. The National Committee to Preserve
Social Security and Medicare is a very reputable organization. That is
what they say.
Who is this 60 Plus association I have heard referred to? Let me just
tell my colleagues what 60 Plus really is. I will read this. This is
from Wikipedia, and it may not be accurate. It says this about 60 Plus:

The 60 Plus Association is an American conservative
advocacy group based in Arlington, Virginia, that bills
itself as the conservatives' alternative to the AARP.

That makes good sense because over the years it has sought to
privatize Social Security. 60 Plus, over the years, has sought to
privatize Social Security. They want to end the Federal estate tax.
They also want to strengthen gun rights, but that is not relevant.

According to the AARP--

And this is a bit biased--

the 60 Plus Association employed the talents of conservative
direct mail mogul Richard A. Viguerie to solicit new members.

We all know who Viguerie is. 60 Plus is a very conservative
organization. I don't think they are real interested in senior
citizens. They have different fish to fry. Also, AARP criticized 60
Plus as being partisan because its issues and causes mirror those of
only one of two major parties, the Republican Party.

A final criticism leveled by the AARP [about 60 Plus] is
that because it lists no dues-paying members and [get this]
receives the majority of its contributions from the
pharmaceutical industry, the group is simply a front
organization for the pharmaceutical industry.

I ask unanimous consent to have these letters in opposition to the
McCain amendment, in support of the Bennet amendment, and the Wikipedia
information printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

Alliance for Retired Americans,

Washington, DC, December 1, 2009.
Dear Senator, The Alliance for Retired Americans, on behalf
of its nearly four million members throughout the nation,
opposes the motion by Senator John McCain to commit the
Patient Protection and Affordable Care America Act, H.R.
3590, to the Finance Committee. We urge its prompt defeat by
the Senate.
The McCain motion to commit would seriously undermine
important, substantive, and positive changes in the health
care needs of older Americans contained in the bill, none
more important than proposed Medicare improvements. In fact,
the McCain motion would increase health care burdens on
Medicare beneficiaries in several instances. The McCain
motion would, for the first time, subject Medicare Part D
prescription drug premiums to means testing, causing a rise
in premiums for many older Americans. In addition, the motion
to commit would halt indexing to Medicare Part B physicians
services premiums, causing even more seniors to pay higher
premiums, which currently can be as much as $300 per month.
Furthermore, the McCain motion would continue the wasteful
Medicare Advantage overpayments that currently threaten the
financial stability of the Medicare Trust Fund.
The Alliance supports provisions in the Patient Protection
and Affordable Care Act that improve health care for older
Americans such as allowing Medicare beneficiaries to keep
their choice of doctors, lowering prescription drug costs,
eliminating copayments for preventive screenings, expanding
access to long-term supports and service, and providing
assistance for pre-Medicare eligible early retirees. All of
these improvements will not be possible should the McCain
motion pass.
The legislation does not cut Medicare benefits. With the
expected rising costs of Medicare, the legislation slows the
rate of the program's growth without reducing benefits. The
McCain motion would actually undercut fiscally responsible
attempts to meet the challenges of providing health care for
older Americans.
The Alliance for Retired Americans is committed to enacting
legislation that improves the quality of life for retirees
and all Americans. Defeat of the McCain motion to commit the
Patient Protection and Affordable Care Act to the Finance
Committee will directly benefit our members and more than
forty million older Americans. If we can be of assistance,
please contact Richard Fiesta, Director of Government and
Political Affairs, at the Alliance.
Sincerely yours,
Barbara J. Easterling,
President.
Ruben Burks,
Secretary-Treasurer.
Edward F. Coyle,
Executive Director.
____

AARP,

Washington, DC, December 2, 2009.
Hon. Harry Reid,
Majority Leader, U.S. Senate,
Washington, DC.
Dear Leader Reid: AARP supports moving forward on health
care reform, and we remain committed to enacting legislation
this year that protects and strengthens Medicare, improves
the delivery of health care and provides affordable insurance
for all. Accordingly, we oppose the amendment offered by
Senator McCain to recommit H.R. 3590 to the Senate Finance
Committee.
As we have said from the outset, AARP supports a balance of
revenues and savings with shared responsibility from
individuals, employers and the government. With respect to
Medicare, AARP supports policies to eliminate waste, fraud
and abuse--and to improve the quality, value and
sustainability of the program for current and future
beneficiaries. The legislation before the Senate properly
focuses on provider reimbursement reforms to achieve these
important policy objectives. Most importantly, the
legislation does not reduce any guaranteed Medicare benefits.
AARP believes that savings can be found in Medicare through
smart, targeted changes aimed at improving health care
delivery, eliminating waste and inefficiency, and
aggressively weeding out fraud and abuse. Such changes will
help strengthen Medicare's long-term financing without
increasing costs for beneficiaries that make health care less
affordable. Medicare provides critical health security to
older Americans, and it is important that Medicare continue
to deliver high quality care. As health care costs, including
Medicare costs, continue to skyrocket, it is essential that
we make changes to improve health care delivery, improve
Medicare's financing, and ensure maximum value for our
Medicare dollars. We believe that Medicare changes in this
bill begin to move us down this path, without reducing
guaranteed Medicare benefits.
With these savings, the legislation before the Senate takes
important steps to improve access to preventive services for
Medicare beneficiaries. However, more should be done to
strengthen Medicare--including closing the Medicare Part D
coverage gap, or ``doughnut hole,'' as pledged by the
President.
We therefore urge you to oppose the McCain amendment to
recommit, and we remain firmly committed to working with you
to strengthen Medicare and enact comprehensive health care
reform this year that improves access and affordability of
health care for all.
Sincerely,
Addison Barry Rand.
____

National Committee to Preserve

Social Security and Medicare,

Washington, DC, December 3, 2009.
U.S. Senate,
Washington, DC.
Dear Senator: On behalf of the National Committee to
Preserve Social Security and Medicare's millions of members
and supports, I am pleased to endorse the amendment of
Senator Michael Bennet of Colorado which clarifies that H.R.
3590, the Patient Protection and Affordable Care Act, would
improve the Medicare program as part of health care reform.
Senator Bennet's amendment puts into law two of the most
important criteria the National Committee has been using when
analyzing health care reform proposals. First, it states
explicitly that the legislation would not reduce any of
Medicare's guaranteed benefits. Second, it ensures that
savings from Medicare would be used to improve Medicare.
Improvements in H.R. 3590 include extending the solvency of
the Medicare trust funds by five years, reducing the amount
of future increases in premiums, eliminating cost-sharing for
preventive benefits, making prescription drugs more
affordable, and ensuring access to Medicare providers.
Protecting Medicare and Social Security has been the
National Committee's key mission since our founding 27 years
ago and remains our top priority today. Our members are no
different than seniors all over this country who are nervous
about rising out-of-pocket health care costs and are
concerned about the Medicare savings in health care reform
legislation. This is a legitimate concern, but it is
important to put these savings

[[Page S12290]]

in perspective. The federal government will spend almost $9
trillion on Medicare in the next decade. The proposed savings
of nearly $500 billion mean that the growth in spending will
be reduced by about two percent over the next 10 years by
eliminating wasteful spending and outright fraud.
The H.R. 3590, the Patient Protection and Affordable Care
Act, includes savings that are designed to protect Medicare
beneficiaries and improve the Medicare program. Senator
Bennet's amendment expressly prohibits any reductions in
guaranteed Medicare benefits and makes sure all savings are
reinvested back into Medicare. I urge you to support the
Bennet amendment which is important to Medicare beneficiaries
and the solvency of the Medicare program.
Cordially,
Barbara B. Kennelly,
President & CEO.
____

National Committee to Preserve

Social Security and Medicare,

Washington, DC, December 1, 2009.
U.S. Senate,
Washington, DC.
Dear Senator: On behalf of the millions of members and
supporters of the National Committee to Preserve Social
Security and Medicare, I am writing to express our opposition
to the amendment offered by Senator McCain which would
recommit H.R. 3590, the Patient Protection and Affordable
Care Act, to the Senate Finance Committee with instructions
to remove important Medicare provisions.
Much of the rhetoric from opponents of health care reform
is intended to frighten our nation's seniors by persuading
them that Medicare will be cut and their benefits reduced so
that they too will oppose this legislation. The fact is that
H.R. 3590, the Patient Protection and Affordable Care Act,
does not cut Medicare benefits; rather it includes provisions
to ensure that seniors receive high-quality care and the best
value for our Medicare dollars. This legislation makes
important improvements to Medicare which are intended to
manage costs by improving the delivery of care and to
eliminate wasteful spending.
The National Committee opposes any cuts to Medicare
benefits. Protecting the Medicare program, along with Social
Security, has been our key mission since our funding 25 years
ago and remains our top priority today. In fact, these
programs are critical lifelines to today's retirees, and we
believe they will be even more important to future
generations. But we also know that the cost of paying for
seniors' health care keeps rising, even with Medicare paying
a large portion of the bill. That is why we at the National
Committee support savings in the Medicare program that will
help lower costs. Wringing out fraud, waste and inefficiency
in Medicare is critical for both the federal government and
for every Medicare beneficiary.
The Senate bill attempts to slow the rate of growth in
Medicare spending by two to three percent, or not quite $500
billion, over the next 10 years. However, it is important to
remember that the program will continue growing during this
time. Medicare will be spending increasing amounts of money--
and providers will be receiving increased reimbursements--on
a per capita basis every one of those years, for a total of
almost $9 trillion over the entire decade. Even with the
savings in the Senate bill, we will still be spending more
money per beneficiary on Medicare in the coming decades,
though not quite as much as we would be spending if the bill
fails to pass.
America's seniors have a major stake in the health care
reform debate as the skyrocketing costs of health care are
especially challenging for those on fixed incomes. Not a
single penny of the savings in the Senate bill will come out
of the pockets of beneficiaries in the traditional Medicare
program. The Medicare savings included in H.R. 3590, the
Patient Protection and Affordable Care Act, will positively
impact millions of Medicare beneficiaries by slowing the rate
of increase in out-of-pocket costs and improving benefits;
and it will extend the solvency of the Medicare Trust Fund by
five years. To us, this is a win-win for seniors and the
Medicare program.
The National Committees urges you to oppose the motion to
recommit the bill to the Finance Committee with instructions
to strike important Medicare provisions from health care
reform legislation.
Cordially,
Barbara B. Kennelly,
President & CEO.
____

60 Plus Association

[From Wikipedia]

The 60 Plus Association is an American conservative
advocacy group based in Arlington, Virginia, that bills
itself as the conservatives' alternative to the AARP,
(formerly the American Association of Retired Persons). Over
the years, it has sought to privatize Social Security, end
the federal estate tax, and strengthen gun rights. Current
issues include opposing health care reform proposals;
opposing federal energy standards; opposing the General
Motors bailout; and opposing tax increases on those earning
more than $250,000 per year. 60 Plus is a member of the
Cooler Heads Coalition, an climate change denial
organization.
According to the AARP, the 60 Plus Association employed the
talents of conservative direct mail mogul Richard A.
Viguerie, to solicit new members. The AARP has also
criticized the 60 Plus Association as being partisan because
its issues and causes mirror those of only one of the two
major United States parties, the Republicans. A final
criticism leveled by the AARP is that because it lists no
dues-paying members and receives the majority of its
contributions from the pharmaceutical industry, the group is
simply a front organization for the pharmaceutical industry.
The organization's website provides positive reviews of its
work by conservative politicians and commentators, including:
``The 60 Plus Association has helped provide the
organization and momentum needed for repeal of the federal
estate or death tax. I commend the Association for its
efforts to abolish this unfair and burdensome tax.''--Rep.
Ralph M. Hall (R-TX)
``Small business leaders recognize how counter-productive
this tax really is. That's why they endorsed repeal of the
death tax and why my bill is supported by the 60 Plus
Association.''--Senator Jon Kyl (R-AZ)
``Jim Martin (who, by the way, gave George W. [Bush] his
first political job) is the head of Washington, DC-based, The
60 Plus Association and one of the country's most vocal
defenders of the tax rights of seniors.''--Mona Lipschitz,
News Editor ``Talkers Magazine'' ``Sources'' Column March
2001.

Leadership

60 Plus is led by its President James L. Martin, a 73-year-
old veteran of the U.S. Marines. Martin has previously led
several conservative advocacy groups, and also was chief of
staff for six years for former Republican congressman and
senator, the late Edward Gurney of Florida. Martin also
served as a member of President George W. Bush's health and
human services transition team.

Funding

In 2001, 60 Plus received a total of $275,000 from the
Pharmaceutical Research and Manufacturers of America, the
group Citizens for Better Medicare, itself largely supported
by the pharmaceutical industry, and three drug companies
(Merck, Pfizer and Wyeth-Ayerst) plus another $300,000 from
Hanwha International Corp., the U.S. subsidiary of a Korean
conglomerate with chemical and pharmaceutical interests--
amounts that made up about 29 percent of its revenue. ``We're
not a front for anybody,'' James L. Martin, the chairman of
60 Plus, told the AARP Bulletin. ``I get money from lots of
sources. I've received money from the pharmaceuticals--I wish
it was more.'' 60 Plus does not provide any explanation of
its funding on its website.
In 2003, President Jim Martin told the British Medical
Journal that 60 Plus had 225,000 members, whom he would not
disclose for privacy purposes. However, according to the
organization's IRS Form 990, 91 percent of its $11 million in
2002 revenue came from one undisclosed source. The Public
Citizen watchdog group suspects that the pharmaceutical
industry was that source. According to the Washington Post,
in 2002, 60 Plus received an unrestricted educational grant
(which can be used as most needed) from the Pharmaceutical
Research and Manufacturers of America. As recently as 2001,
60 Plus has not reported any member dues as revenue on its
past tax returns, reported the AARP Bulletin.
60 Plus also earns income from sponsoring life insurance
and health screening for its members.

Health Care Reform

On August 7, 2009, 60 Plus released a TV ad to be aired on
cable networks to inform viewers about the proposed U.S.
health care reform legislation. Media Matters for America
watchdog group found that the ad was largely false and used
``scare tactics'' to discourage voters from backing reform.
To publicize the ad's launch, 60 Plus issued a press release
titled ``Massive Medicare Cuts Await Elderly Says New Ad From
Seniors Group'' that read in part, `` . . . The healthcare
proposal touted by the Obama Administration means massive
Medicare cuts in order to pay for healthcare `reform'.'' 60
Plus provided no evidence of these supposed ``massive
Medicare cuts.''

Mr. BAUCUS. Mr. President, I think it is pretty clear that the main
organizations that care about seniors support this bill. Another
organization--60 Plus--I don't know what they think. I guess they
oppose it because they want to privatize Social Security, and they get
most of the money from the pharmaceutical industry. I don't think they
care about senior citizens, frankly, and certainly not as much as these
other organizations.
I think it is also important to point out that this legislation is
deficit neutral over not just the first 10 years but over the next 10
years. It is more than deficit neutral. This legislation generates a
$130 billion surplus the first 10 years and, as we all know, reduces
the budget by a quarter of GDP over the next 10 years. So this is not
irresponsible; it is very fiscally responsible. It is strongly
supported by the senior organizations that care for seniors. I might
say, too, it is not raiding Medicare at all. It is strengthening the
Medicare trust fund and it extends the solvency of the trust fund.
Therefore, I think, clearly, as AARP says, we should oppose the
McCain amendment, which hurts Social Security beneficiaries, does not
help them.

[[Page S12291]]

I yield such time as the Senator from Illinois needs.
The PRESIDING OFFICER. The Senator from Montana has 9 minutes 20
seconds, and the other side's time has expired.
Mr. DURBIN. Mr. President, I ask to be recognized for 5 minutes. If
the chair would advise me when I have used that time.
I found it interesting, as I am sure the Senator from Montana has, to
listen to all of the Republican Senators who have come to the floor to
defend Medicare. I am sure the Senator from Montana has the same memory
I do--that when it was created, it was created by the Democratic side
of the aisle, with the general opposition of the Republican side of the
aisle. They said it was socialized medicine, too much government, and
it would fail. Now they are coming riding to the rescue of Medicare. We
have a right to be skeptical about the arguments they are making.
Imagining these Republican Senators defending Medicare is trying to
imagine a fish riding a bicycle. I cannot put it in my mind. But they
are doing it. The Senator who sponsored this motion to commit, Senator
McCain, just a year ago, in the course of his Presidential campaign,
called for eliminating $1.3 trillion in spending from Medicare and
Medicaid. Now he comes to the floor and says this bill, which would
reduce costs in Medicare by less than half of that amount over a 10-
year period of time is irresponsible and the death knell of Medicare.
What is the real story? The real story is the Republican side of the
aisle is defending the private health insurance companies--companies
making generous profits from Medicare Advantage. This is a program
offered by private health insurance companies to replace government-run
Medicare. It turned out, in many instances, to have failed miserably.
It costs more money because these private health insurance companies
are taking profits out of the Medicare Advantage Program. So they have
pleaded with the other side of the aisle to come to their rescue. They
have sent in their best troops on the other side of the aisle, headed
by the senior Senator from Arizona, who has said the first thing I will
do is to protect these private health insurance companies and their
rights to overcharge seniors in Medicare for Medicare Advantage.
He talks about the people now receiving Medicare Advantage, who may
be disadvantaged and see a different policy in the future. What the
Senator from Arizona and others don't dwell on is that everybody under
Medicare today pays $90 a year more into Medicare to subsidize the
private health insurance companies that offer Medicare Advantage. This
is a tax--a tax--which the Senator from Arizona is trying to preserve.
It is a tax on Medicare recipients.
The Senator from Arizona was right a year ago. We can take an honest
look at Medicare and Medicaid and take money out of the system without
disadvantage to the people involved.
I want to say to the Senator from Arizona and others that once we
have dispatched his motion to commit, he will have a chance to vote for
Senator Michael Bennet's amendment. It could not be clearer. It has two
parts. It says--repeating what this bill says, it says unequivocally:

No provision in this Senate bill can reduce any Medicare
benefit guaranteed by statute.

Next paragraph:

Savings in Medicare from the bill will go to extend the
life of the Medicare trust fund, lower part B premiums, or
cost sharing, expands benefits, improves access to providers.

We know, and the seniors across America know, that left unattended
and uncared for, Medicare may go broke in just a matter of 7 or 8
years. This bill before us will extend the life of Medicare for at
least 5 years. It will put Medicare on sound footing which every senior
and their families want to have. That is why AARP, the largest
organization of senior citizens across America, has urged Members of
the Senate in both parties to oppose the McCain motion to commit. That
is why I stand today with the Senator who is chairman of the Finance
Committee and say to my Republican friends, with their newfound love
affair with Medicare, that they should reject the 60 Plus organization,
this ``wise counsel'' they turned to that came up with the idea of
privatizing Social Security.
How would you like to have had all your Social Security money in the
stock market over the last 2 years? Boy, there is a great idea. Stick
with this 60 Plus group if you like the notion of privatizing Social
Security. Stick with AARP if you want Medicare to be strong, on sound
financial footing.
I yield the floor.
The PRESIDING OFFICER. The senior Senator from Montana is recognized.
Mr. BAUCUS. Mr. President, I think it is appropriate to remind people
of some of the provisions that are in this bill.
To repeat, because some people have listened to some of this debate
and some have not and some might be tuning in right now, the fact is,
without reform, without this legislation, Medicare is expected to go
broke in the next 8 years. That is according to the Medicare trustees
report. With this legislation, that is extended for at least 5 more
years. That protects seniors. This legislation protects seniors.
Without reform, that is, without this bill, costs will rise and seniors
will be forced to bear more and more of the burden out of their own
pockets. This legislation adds benefits for seniors. It does not take
it away, as the other side implies.
Without reform, seniors will struggle to afford prescriptions in the
doughnut hole. I remind my colleagues that this legislation will cut
the cost of brand-name prescription drugs in half for seniors during
that gap, the so-called doughnut hole.
It will also help provide more benefits in terms of annual wellness
visits. When seniors go to the doctor for a colonoscopy, mammography,
or other preventive screenings, they will not have copays, as is
currently the case today. That is an added benefit this legislation
provides for seniors.
Also, this legislation helps seniors who are eligible for both
Medicare and Medicaid with access to home, community-based
alternatives. A lot of our seniors would like that additional benefit.
That is all in this legislation.
This legislation provides more benefits for seniors, not fewer. This
legislation protects seniors; it does not harm them. This legislation
extends the solvency of the trust fund rather than not.
I might also say--and I think the Senator from Illinois made a very
good point--currently, seniors who are paying a Part B premium are
really paying a $90 tax per year for those persons who are in Medicare
Advantage. We know Medicare Advantage is overpaid. The Senator from
Oklahoma, Mr. Coburn, agreed with me when I asked him just yesterday if
Medicare Advantage was overpaid. He said, yes, it is overpaid by a very
large margin. This legislation can adjust that overpayment.
I might also say, too, that the groups I mentioned support this
legislation. But the main point I want to make is this: There are so
many fundamental provisions in this legislation that really have not
come out much in debate, a little esoteric but under the heading of
``delivery system reform.'' We must begin to change the way we
reimburse doctors and hospitals so we are focusing much more on quality
of care rather than quantity of care. Some of that is already happening
in America without legislation. Basically, it is the nature of
integrated systems. We all talked about them. I know Senators on the
other side of the aisle also agree with this new trend where hospitals,
doctors, nursing homes, and other groups get together and they
coordinate their care. Their care is much more patient focused. We have
to move much more in that direction.
This will go a long way once it starts kicking in--it is going to
take maybe 3 or 4 years to finally have an effect--toward eliminating
the waste in our current system. Estimates are we have between $200
billion to $300 billion to $800 billion annually in waste in the
American health care system. That is the reason health care costs are
so high for family, businesses, governments, whatnot. We have to begin
to get that under control, and this legislation does that.
If we do not pass this legislation, we will be postponing the day
when we have to begin to get some of these excessive costs under
control, and then the problem will be much more difficult. An ounce of
prevention is worth a pound of cure in medicine. It is also true in
legislation. Clearly, now is the

[[Page S12292]]

time to exercise a little ounce of prevention by starting to curb
excessive costs, and this bill does that.
Mrs. LINCOLN. Mr. President, with a mother who is covered by
Medicare, I remain committed to protecting seniors' access to Medicare,
just as I have throughout my public service, which is exactly why I am
opposed to the McCain motion to commit. Mr. McCain's purpose is not to
protect Medicare but to frighten our Nation's seniors so that they too
will oppose health care reform. I have noted that he has taken his
scare tactics to a new level by recording his voice for an automated
phone call into my State claiming to seniors that these Medicare
savings are going to cut their benefits. He urges them to call me. I
believe the seniors in my State know me better than that. They know
that I have worked my entire career in this body to protect Medicare.
I have cosponsored the Bennet amendment as an extra safeguard to
ensure our seniors that this bill does not cut the guaranteed Medicare
benefits that they receive today and that any savings generated from
making the Medicare Program more efficient will go back into
improvements to the program.
If we do nothing, the Medicare Program will be broke in just 8 years.
This bill restores the program's solvency beyond 2022. It will reduce
premiums and copays for seniors; ensure seniors can keep their own
doctors; cut the billions of dollars of waste, fraud, and abuse that
occur annually; provide new prevention and wellness benefits for
seniors; lower their prescription drug costs; and help them to stay in
their own homes rather than going to nursing homes if that is what they
wish to do.
So what about the $500 billion in Medicare cuts Republicans say
seniors should be worried about? Well, what they are not saying is that
part of the reason Medicare is insolvent is the fact that private
insurers under the Medicare Advantage Program are overpaid by 14
percent on average. A typical couple pays $90 more per year in Part B
premiums to pay for Medicare Advantage overpayments, even if they are
not enrolled in these plans. This bill curbs those overpayments, saving
over $118 billion, by for the first time requiring competitive bidding
of Medicare Advantage plans against one another. Furthermore, Medicare
and Medicaid subsidies to hospitals that help them cover the cost of
the uninsured will be reduced since hospitals will have less need for
them once millions more Americans have health insurance. That is
another $43 billion. Provision after provision is specifically designed
to ensure greater value in Medicare, all while the Republicans are
using fear tactics to score political points.
I have heard from many seniors in Arkansas, recently, and over the
years, about their satisfaction with Medicare. It is not a perfect
program, and as a Senator it is my job to ensure that Congress continue
to improve upon the program as needed so that it can continue to meet
the needs of our Nation's seniors. Rightly so, seniors in my State are
concerned about the misinformation spreading that we will cut their
benefits and allow bureaucrats to ration their care. Organizations such
as AARP, the Alliance for Retired Americans, and the National Committee
to Preserve Social Security and Medicare have stood up to say enough
with the misinformation campaign. Today I add my voice to that chorus.
Mr. FEINGOLD. Mr. President, I opposed Senator McCain's attempt to
send the bill back to committee because it would have effectively ended
the current debate on health care reform. Moreover, while I have
concerns about some of the offsets in the bill--such as cuts to hospice
and home health care--it would be fiscally irresponsible to throw out
provisions that cut down on wasteful spending and reward quality, as
the McCain motion would have done. Those provisions are key to helping
to put Medicare on the path to long-term fiscal sustainability.
The PRESIDING OFFICER. The Senator's time has expired. The next 10
minutes is evenly divided between the Senator from Colorado and the
Senator from Arizona.
Mr. McCAIN. Mr. President, I yield 2 minutes to the Senator from
Iowa.
The PRESIDING OFFICER. The senior Senator from Iowa is recognized for
2 minutes.
Mr. GRASSLEY. Mr. President, as I stated earlier, the Bennet
amendment, as written, does not protect Medicare. So I have a
modification I would like to present that ensures Medicare savings in
this bill are not being siphoned off to finance a new and separate
entitlement program.
To that end, I ask unanimous consent to modify the amendment by
adding the following before the period at the end of subsection (b):

. . . and furthermore that, notwithstanding any other
provision of this Act or amendment made by this Act, net
Medicare savings specified in the most recent estimate
available from the Director of the Congressional Budget
Office before enactment are appropriated to the Secretary and
shall be used for such purposes and to maintain Medicare
policies for home health services, skilled nursing facility
services, hospice care, hospital services, and benefits
provided by the Medicare Advantage program, as under the
provisions of such Title as specified on the day before the
date of enactment of this Act.

End of my amendment.
The PRESIDING OFFICER. Is there objection?
Mr. BAUCUS. Reserving the right to object, under current law, if less
is spent for Medicare providers, the benefits inure to the Medicare
trust fund beneficiaries.
Although I have the greatest respect for the Senator from Iowa, this
is a stunt, and I object.
The PRESIDING OFFICER. Objection is heard.
Mr. GRASSLEY. Then if I may?
The PRESIDING OFFICER. The Senator from Iowa.
Mr. GRASSLEY. Mr. President, I would like to make very clear that
this objection confirms that the Bennet amendment does not protect
Medicare as the other side claims that it protects Medicare.
I yield the floor.
The PRESIDING OFFICER. Who yields time? The Senator from Arizona is
recognized.
Mr. McCAIN. Mr. President, this motion sends the legislation back to
the Finance Committee for a short period of time with instructions to
report back with cost offsets other than Medicare cuts. The motion says
we should retain the provisions in the legislation addressing fraud and
abuse and retain those savings to strengthen the Medicare trust fund.
Instead of cutting over $450 billion from Medicare providers and
beneficiaries, the committee should do what it should have done in the
first place--protect seniors' benefits and access to providers. It is
much needed.
Mr. President, I say to my friends, let's save seniors who have paid
into the Medicare Program their whole lives from these damaging cuts. I
hope my colleagues will vote in favor of this motion. Let's use
Medicare savings to save Medicare, not to fund a whole new $2.5
trillion entitlement program. I urge a vote in favor of the motion.
I yield back the remainder of my time.
The PRESIDING OFFICER. The Senator from Colorado is recognized for 5
minutes.
Mr. BENNET. Mr. President, I wish to sum up the debate over Medicare
in the Senate health bill and on the motion and amendment before us.
Only in Washington, DC, could an effort to extend the life of
Medicare somehow be distorted as being bad for seniors. We know from
the Congressional Budget Office, a nonpartisan organization that
supports both sides of the aisle, that this Senate bill does not take
away any seniors' guaranteed Medicare benefits. It extends Medicare
solvency for 5 additional years. My amendment simply confirms these two
facts.
I am the first person who would insist we have an open process for
this debate. I think there are ideas on each side of this debate on
this bill that are worth considering and should be considered. But it
is why I find it so confounding that opponents of my amendment want to
send the entire bill back to committee so debate stops. How can we
return home to the people of our States and admit to them we just gave
up and sent health care back to the committee for another round?
The people who do not want change are the people who are content to
leave it the same and do not have a theory about how to extend
Medicare. They would have seniors believe the bill is bad for seniors.
Yet AARP, the Alliance for Retired Americans, the Center

[[Page S12293]]

for Medicare Rights, and the National Committee to Preserve Social
Security and Medicare beg to differ. They disagree. They agree with
this amendment and with the underlying bill. Senior advocacy
organizations, grassroots organizations with their ears to the ground
hearing the voices and concerns of seniors, support health care reform,
and they agree that with my amendment, this bill strengthens Medicare
and preserves seniors' benefits.
With the Senate bill finally reaching the floor, seniors are looking
for simple clarity on how health care reform can help their lives.
Nothing in this bill will cut guaranteed Medicare benefits, and this
bill will extend Medicare solvency for 5 additional years. It actually
makes the system work better instead of cutting or adding to a program.
It actually changes the way Medicare works so it will be stronger and
more stable.
People may disagree with the prescription, but as a general matter
everybody knows the status quo is unsustainable, and this bill helps
seniors. It eliminates the copay seniors have to pay for preventive
care. We know preventive care saves lives and it saves money.
As we close debate on my amendment and the alternative motion to
commit the bill to committee, I urge all the Members of this body to
consider the consequences of inaction. My amendment affirms what the
current Senate bill does to help seniors and strengthen Medicare. We
all know even more can be done, so let's continue this debate and
reject the motion to commit the bill back to the Senate committee.
I urge every Member of this body to support my amendment. Please vote
yes on the Bennet amendment and protect our seniors.
I yield the floor.
The PRESIDING OFFICER. Who yields time?
Mr. BAUCUS. How much time remains?
The PRESIDING OFFICER. The Senator from Montana has 1 minute 50
seconds.
Mr. BAUCUS. The Senator from Arizona has yielded back his time. We
might as well yield back our time, and we can vote.
The PRESIDING OFFICER. The Senator from Arizona yielded back his
time. The Senator from Montana yields back his time. All time is
yielded back.
The question is on agreeing to amendment No. 2826.
Mr. McCAIN. Mr. President, have the yeas and nays been ordered?
The PRESIDING OFFICER. They have not.
Mr. McCAIN. I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There is a sufficient second.
The clerk will call the roll.
The legislative clerk called the roll.
The result was announced--yeas 100, nays 0, as follows:

[Rollcall Vote No. 357 Leg.]

YEAS -- 100

Akaka
Alexander
Barrasso
Baucus
Bayh
Begich
Bennet
Bennett
Bingaman
Bond
Boxer
Brown
Brownback
Bunning
Burr
Burris
Byrd
Cantwell
Cardin
Carper
Casey
Chambliss
Coburn
Cochran
Collins
Conrad
Corker
Cornyn
Crapo
DeMint
Dodd
Dorgan
Durbin
Ensign
Enzi
Feingold
Feinstein
Franken
Gillibrand
Graham
Grassley
Gregg
Hagan
Harkin
Hatch
Hutchison
Inhofe
Inouye
Isakson
Johanns
Johnson
Kaufman
Kerry
Kirk
Klobuchar
Kohl
Kyl
Landrieu
Lautenberg
Leahy
LeMieux
Levin
Lieberman
Lincoln
Lugar
McCain
McCaskill
McConnell
Menendez
Merkley
Mikulski
Murkowski
Murray
Nelson (NE)
Nelson (FL)
Pryor
Reed
Reid
Risch
Roberts
Rockefeller
Sanders
Schumer
Sessions
Shaheen
Shelby
Snowe
Specter
Stabenow
Tester
Thune
Udall (CO)
Udall (NM)
Vitter
Voinovich
Warner
Webb
Whitehouse
Wicker
Wyden
The PRESIDING OFFICER (Mr. Kirk). On this vote, the yeas are 100, the
nays are 0. Under the previous order requiring 60 votes for the
adoption of this amendment, the amendment (No. 2826) is agreed to.
Mr. DURBIN. Mr. President, I move to reconsider the vote.
Mrs. BOXER. I move to lay that motion on the table.
The motion to lay on the table was agreed to.

Motion To Commit

The PRESIDING OFFICER. There will now be 2 minutes of debate equally
divided on the motion to commit offered by the Senator from Arizona.
The Senator from Montana is recognized.
Mr. BAUCUS. Mr. President, I ask my colleague if he wishes to go
first? Whatever he wants to do. It is his motion.
Mr. McCAIN. Please go ahead.
Mr. BAUCUS. Mr. President, the McCain motion is next. Unless we act
today and pass health care reform, the Medicare trust fund runs out of
money in 2017. There are two ways to keep Medicare solvent: find
efficiencies so Medicare spends less or increase revenues going into
the trust fund--two ideas. Our bill would make Medicare Advantage more
efficient. We would introduce competitive bidding----
Mr. BYRD. Mr. President, may we have order? We have a Senator
speaking here. May we have order?
I thank the Chair.
Mr. BAUCUS. I thank the Senator from West Virginia.
We extend the trust fund for 5 more years. That is in this bill. Yes,
Medicare Advantage plans would not be overpaid as much, but those plans
could pay for greater efficiency by cutting their profits or cutting
their executives' pay. They could do that. Nothing says they have to go
after beneficiaries.
Our bill does nothing to reduce the guaranteed Medicare benefits. To
the contrary, our bill would improve Medicare benefits. It would help
seniors on the prescription drug doughnut hole and add new preventive
benefits such as annual wellness visits. The bill would help ensure
doctors would be available to treat Medicare patients. We would prevent
the 21-percent cut in doctor payments under current law. For all those
reasons, the American Association of Retired Persons supports reform
and opposes the McCain motion.
I urge my colleagues to support reform and oppose the motion to
commit.
Mr. McCAIN. Mr. President, this motion proposes to send the
legislation back to the Finance Committee to remove the nearly $\1/2\
trillion in cuts that will severely impact all seniors who are eligible
for Medicare. As the Senator from Montana mentioned, the system is
going to go broke in 7 years. So what does this legislation
contemplate? That we take $\1/2\ trillion out of their savings and use
it to fund a $2.5 trillion new entitlement program. What does that do
for the Medicare trust fund? Nothing.
I urge my colleagues to vote in favor of this motion and send it back
to the Finance Committee. Do the right thing for the seniors of this
country.
Mr. BOND. Mr. President, I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second? There is a
sufficient second.
The question is on agreeing to the motion. The clerk will call the
roll.
The assistant legislative clerk called the roll.
The result was announced--yeas 42, nays 58, as follows:

[Rollcall Vote No. 358 Leg.]

YEAS--42

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

NAYS--58

Akaka
Baucus
Bayh
Begich
Bennet
Bingaman
Boxer
Brown
Burris
Byrd
Cantwell
Cardin
Carper
Casey
Conrad
Dodd
Dorgan
Durbin
Feingold
Feinstein
Franken
Gillibrand
Hagan
Harkin
Inouye
Johnson
Kaufman
Kerry
Kirk
Klobuchar
Kohl
Landrieu
Lautenberg
Leahy
Levin
Lieberman
Lincoln
McCaskill
Menendez
Merkley
Mikulski
Murray
Nelson (FL)
Pryor
Reed
Reid
Rockefeller
Sanders
Schumer
Shaheen
Specter
Stabenow
Tester
Udall (CO)
Udall (NM)
Warner
Whitehouse
Wyden
The PRESIDING OFFICER. On this vote, the yeas are 42, the nays are
58.

[[Page S12294]]

Under the previous order requiring 60 votes for the adoption of this
motion, the motion is withdrawn.
Mr. BAUCUS. Mr. President, I move to reconsider the vote.
Mr. HARKIN. I move to lay that motion on the table.
The motion to lay on the table was agreed to.
The PRESIDING OFFICER. The majority leader.
Mr. REID. Mr. President, I ask unanimous consent that the Senate be
in a period of debate only between now and 4:30. It is my understanding
there has been an agreement that at 4:30 we will all go to the
classified room in the Visitor Center to listen to what the
administration has to say about Iraq and Afghanistan. I haven't had a
chance to clear this with the Republican leader, but for the next hour
we will remain in a period of debate only and come back and offer the
amendment after we finish with the classified briefing.
We have not yet had agreement to recess at 4:30. I ask unanimous
consent that we recess from 4:30 until 5:30 for a classified briefing.
The PRESIDING OFFICER. Without objection, it is so ordered.
The Senator from Idaho.
Mr. CRAPO. Mr. President, I wish to continue discussing the health
care legislation we just voted on. We had a series of votes dealing
with the Medicare issue. I wish to start my remarks by turning to the
Senator from Mississippi, Mr. Wicker, and ask him if he has comments he
wishes to make.
Mr. WICKER. Mr. President, I appreciate the Senator yielding to me. I
think it is important for us all to understand where we are now. We
have had a debate about the Medicare issue. The Senate had an
opportunity, with the McCain amendment, to protect Medicare from the
almost one-half trillion dollars in cuts the Reid bill proposes to do
to Medicare. We said no to that opportunity and instead passed the
amendment offered by Senator Bennet of Colorado which in sum total does
absolutely nothing. What we have done now with the Bennet amendment is
say that along with apple pie and motherhood, we also love Medicare,
and we want everybody to know that. But the substantive effect of what
we have now done is nothing.
I have this challenge to the managers of the bill on the other side
and to the Democratic leadership: Now that Bennet has passed and McCain
has been defeated, I challenge them to take this bill, send it back to
CBO and CMS and have the independent analysts there look at it again.
They will be duty bound to come back with the facts. The facts will be
that the almost one-half trillion dollars cut in Medicare is still
there.
Now that the McCain motion to commit has been defeated, and the sham
of the Bennet amendment has been passed, there are still the same cuts
to hospitals, there are still the same cuts to Medicare Advantage and
to all the senior citizens who depend on that and who were told during
the campaign their coverage would not be taken away from them if they
liked it. The cuts to nursing homes are there. The cuts to home health
are there. And the cuts to hospice are still there.
Send the bill back to CBO. We can continue debating it. We will not
have to miss out on one bit of rhetoric that we have already had. But
ask the independent analysts: Are the Medicare cuts still there? They
will be duty bound to come back to us and say: Yes, the same cuts that
were there before are current in the bill now.
We have accomplished absolutely nothing today to protect Medicare.
I thank the Senator for yielding.
Mr. CRAPO. Mr. President, I thank the Senator from Mississippi.
Mr. President, I ask unanimous consent that several of my colleagues
and I may engage in a colloquy during the time we have.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. CRAPO. Thank you, Mr. President.
I wish to follow up on the comments of Senator Wicker from
Mississippi because it is very critical that the American public
understand what has happened in the Senate.
When you talk about health care reform, the vast majority of
Americans have a couple of ideas in mind. First and foremost, they want
to lower health care premiums and costs. That is what Americans think
about primarily when they think about the need for health care reform.
They also want to see better access to quality health care and make
sure those who are uninsured have access to health care, and those who
are underinsured have access to health care, and that we all have
access to quality health care. That is what this debate should be
about.
But, instead, the legislation we see before us does not achieve that.
Does it reduce the cost of health care? No. It drives up the cost of
health care. It raises taxes hundreds of billions of dollars. It cuts
Medicare by hundreds of billions of dollars. It grows government by
$2.5 trillion of new spending. It forces the most needy in our society
into a failing Medicaid system. It imposes a damaging unfunded mandate
on our struggling States. It still leaves millions of Americans
uninsured and establishes massive government controls over our health
care economy, including the creation now of a government insurance
company.
We have been focusing in the debate on one part of this for the last
little while; that is, the Medicare cuts. Mr. President, $464 billion
of the revenue to pay for this massive new entitlement that is being
created is to come from Medicare, and it is nothing other than a direct
transfer of assets in the United States from America's seniors in the
Medicare system to a new government entitlement program.
There are other cuts. There are details of these cuts that I will put
up right now on a chart.
The debate we have been having over the last, oh, almost 3 or 4 days
now, is whether we should commit the bill back to the Finance Committee
so these Medicare cuts can be removed. We just had two votes. One was
what I will call a cover vote. It said we do not want to cut Medicare
benefits and we should make sure that anything we do protects Medicare.
It did not have any detail in it, but it passed 100 to nothing because
it does nothing. It does not change what is in the bill. By the way, as
I said, that vote just passed by 100 to nothing.
The second vote we took failed. Was the vote 40 to 60? I do not
recall the exact vote. What would that amendment have done? That
amendment would have put the bill back into the Finance Committee and
required that we take out the Medicare cuts.
So let no one be confused, after the first round now in the Senate,
we still see this in the bill--a transfer of $464 billion from the
Medicare Program to the establishment of a new entitlement program. I
do not believe that is what Americans had in mind when they were
talking about reform of health care.
There has been a study that came out--OK. I have the exact vote here.
It was not 40 to 60. It was 42 to 58, but it was defeated, in any
event, and now we still have the cuts to Medicare in the bill. Well, we
are going to continue debating this issue.
I myself have an amendment that will send--for the skilled nursing
homes--the bill back to Finance to correct the cuts for the skilled
nursing homes. There are others who will try to address some of the
pieces of this legislation to see if we can't find a way to fix and
restore the strength and stability of the Medicare system.
Everyone admits we need to reform Medicare. But until this bill, none
of us thought we were talking about taking from Medicare in order to
create a massive new entitlement program, with the government control
that comes along with it.
What do these cuts do? I am going to start out with the hospitals,
the hospice services, the nursing homes, and the home health agencies.
The reduction in Medicare spending on these medical providers will
basically result in lower access to care for our seniors. I have had
representatives in my office of both skilled nursing facilities and
home health agencies who have talked to me about what this means to
them. They have pointed out that the last time Congress did something
like this, we lost, in Idaho, 30 percent, for example, I believe it is,
of our home health agencies. They are not there anymore. If we have
these kinds of deep cuts in the future, we are going to lose more of
our home health care agencies.

[[Page S12295]]

One of the owners said to me--he put it this way: If you reduce the
allocation of income to home health agencies, I have to either reduce
employment, which means not hire as many nurses and medical providers,
or I have to close parts of my building and stop operating as many
rooms in the building, or do something to reduce costs.
What that means is that seniors will have less access. But that is
not all this bill does. In addition to reducing the access for
hospitals, hospice service, nursing homes, and home health agencies, it
also cuts Medicare Advantage deeply.
Quickly, what is Medicare Advantage? Medicare Advantage is a program
that about one out of four American seniors participate in in Medicare.
It is an opportunity which Congress started a few years back to try to
let the private sector become a part of the delivery system in
Medicare. In other words, to put it simply, private sector insurance
companies can contract with the Federal Government to provide Medicare
services to Medicare beneficiaries, so it is the private sector getting
involved in health care delivery rather than the government simply
delivering the health care through a single-payer system. That, in a
quick summary, is what Medicare Advantage was all about.
What we found was that it was phenomenally successful because the
private sector was able, through its management, to not only provide
the statutorily required Medicare coverage but additional benefits,
very critical additional benefits, such as preventive health care,
dental coverage, vision coverage, and things such as that--things that
make a big difference in the lives of our seniors and enables some of
those who cannot buy additional coverage for those things Medicare does
not cover to get access to it through Medicare Advantage.
That is why in my State 27 percent of all of the Medicare recipients
have moved to Medicare Advantage. It is the most popular part of
Medicare in America today, and it is growing faster than any other part
of Medicare because it is delivering more to the Medicare
beneficiaries.
This bill slashes $120 billion from it, some of us believe because
there is a bias against the private sector delivery of health care. But
for whatever reason, the Medicare Advantage portion is where the cuts
are focused.
Let's put up the next chart.
When we had the issue before the Finance Committee, we had the head
of CBO before us, and I asked him a question about the cuts to Medicare
Advantage. We had a colloquy between us at that point, and I asked:

So, approximately half of this additional benefit--

In other words, these additional things that Medicare Advantage has
been able to provide to our seniors under Medicare--

So, approximately half of this additional benefit would be
lost to those current Medicare Advantage policyholders?

And his response was:

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

The point being, not only will we lose skilled nursing facilities,
home health care, hospice care, and hospital care, and access to that
care, we are also going to see senior citizens lose benefits. Again,
what is the purpose? The purpose is not to shore up Medicare. In fact,
it will take $464 billion--taxpayer dollars that are allocated to
Medicare in our current system--and transfer that straight over to the
establishment of a new entitlement program.
I want to let my colleague from Nevada comment on this for a minute,
but before I turn it over to my colleague from Nevada, I wish to point
out that as we approach this issue, the question of why would we
transfer $464 billion out of the Medicare system to a new government
entitlement program, one of the reasons is because the President
pledged he would not sign a bill that did not reduce the deficit.
As I said earlier, this bill grows the spending in the Federal
Government by approximately $2.5 trillion over the first full 10 years
of its implementation of spending. The only way to cover that increase
in the size of the government is to either raise more taxes or to cut
spending somewhere, and what the bill does is both. It raises taxes--
which we are going to be talking about in future days--and it cuts
spending. The place where it cuts spending is Medicare. That is why
what we see is increased taxes, cuts in Medicare, growth of government,
and the establishment of a new Federal entitlement program, with all of
the accompanying accoutrements of Federal control, including a new
government owned and operated insurance company.
I see my colleague from Nevada standing and turn to him for his
comments on this issue.
Mr. ENSIGN. First of all, I think my colleague from Idaho has made
some excellent points about, truly there will be cuts that are going to
happen in Medicare. And do not just take the politicians' word for
these cuts. Listen to the CBO Director. He is the nonpartisan, I
repeat, nonpartisan, official scorekeeper. When asked direct questions,
by not only the Senator from Idaho but others, he absolutely says the
benefits, especially under Medicare Advantage, will be cut.
In my home State of Nevada, tens of thousands--I think about 200,000
altogether--of seniors have voluntarily chosen Medicare Advantage over
traditional Medicare. The reason? Very simple. There are extra benefits
in Medicare Advantage. You hear the Democrats talk about the doughnut
hole in Medicare Part D, which is prescription drug coverage. Well,
there is not a doughnut hole under most of the Medicare Advantage plans
because the private sector, through its efficiency, has been able to
fill that doughnut hole. In other words, they get complete coverage of
prescription drugs through their Medicare Advantage plans.
Also, under Medicare Advantage, they get additional preventive health
care services. They also get vision and dental. And depending on the
plan, depending on its makeup, there are different types of benefits to
attract seniors to certain plans. It is no wonder that about one out of
four seniors in America have voluntarily signed up for Medicare
Advantage. Nobody forced them into this system. They voluntarily chose
this system.
If you think about it, seniors do not like change. For most seniors,
they like what they have. They do not like to change. For one out of
four seniors to have voluntarily changed, there has to be something
pretty attractive about Medicare Advantage.
There are some real attractive things for seniors in Medicare
Advantage plans. That is why when you actually poll seniors regarding
Medicare Advantage, the vast majority of them are thrilled with the
coverage they have. They do not want to lose benefits. Who would want
to voluntarily lose benefits?
But with the $120 billion cut in Medicare Advantage the Democratic
majority has put in this bill, about half of the benefits in Medicare
Advantage plans will be cut. Isn't that correct, I ask my friend, the
Senator from the State of Idaho?
Mr. CRAPO. The Senator from Nevada is correct. In fact, I am just
thumbing through here to get the exact statistics. But the bottom line
is, the CBO indicated, I think it was something like from an average
number of $140 or so of extra benefits--that it would go down to about
half of that. So they would get about half of those extra benefits.
Mr. ENSIGN. That is per month?
Mr. CRAPO. Per month.
Mr. ENSIGN. So $140 per month. According to CBO, about half of those
benefits would be cut under this plan, isn't that correct?
Mr. CRAPO. That is correct.
Mr. WICKER. If the Senator would yield on that point.
Mr. CRAPO. I would be happy to yield.
Mr. WICKER. We have three Republicans standing now saying this, and
we have had quoted some official independent sources. Let me quote a
Democrat, Representative Michael McMahon of New York:

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

That is why that Democrat from the State of New York voted no on the
plan when it was before the House of Representatives. So you don't have
to take our word for it, from a partisan standpoint. Democrats are
saying no because of the Medicare cuts and the cuts to Medicare
Advantage--drastic cuts.
Mr. ENSIGN. The Senator from Idaho and I serve on the Finance
Committee

[[Page S12296]]

where a large portion of this bill was written. We both heard Democrats
on the other side of the aisle complaining about cuts to Medicare
Advantage. Yet when I look in this bill, the total dollar figure in
cuts to Medicare Advantage is the same as what came out of the Finance
Committee; isn't that correct?
Mr. CRAPO. The Senator from Nevada is correct. I have in front of me
the exact numbers right now from CBO that were provided in the Finance
Committee markup. During the markup, CBO estimated that the value of
the extra benefits offered by Medicare Advantage plans will drop from
$135 a month to $42 a month, based on the cuts contained in that bill,
which are essentially the same level of cuts we now see in the bill
before us on the floor.
Mr. ENSIGN. Let me make a couple other general points about this
bill. I think we have pretty well covered the fact that Medicare
Advantage is going to take a severe hit. Medicare overall, that
includes hospice care, hospital care, nursing home care, home health--
all of them are taking severe cuts. More than likely, those cuts are
going to come, if the government doesn't rescue those cuts in the
future, from benefits to seniors.
If the government decides not to have those cuts in the future, then
the deficit is going to go up. You can't have it both ways. You can't
have both a deficit-neutral bill and not have the cuts in Medicare. In
other words, you are going to either have the cuts in Medicare or you
are going to have ballooning deficits into the future.
There are several other problems with the bill that I would like to
point out. First of all, we know it is over 2,000 pages; there is
incredibly complex language in those over 2,074 pages. It places
bureaucrats in charge of health care decisions instead of creating a
patient-centered health care system that says the doctor-patient
relationship is where most of the health care choices should be made.
As a matter of fact, according to the National Center for Policy
Analysis, in almost 1,700 places in this bill it authorizes the
Secretary of Health and Human Services to ``make, create, determine, or
define'' things regarding health care policy. Mr. President, 1,697
times, to be exact, the Secretary of Health and Human Services
basically makes health care policy--not doctors, not health care
providers; bureaucrats in Washington, DC.
You mentioned before there were $\1/2\ trillion in new taxes and
about $\1/2\ trillion in Medicare cuts. We know this bill will lead to
millions of Americans having increased premiums.
We have talked a lot about what is wrong with the bill, however, many
on this side of the aisle have offered positive solutions. We have
talked about allowing small businesses to join together to take
advantage of purchasing power that big businesses have. We have talked
about allowing people to buy insurance across State lines. Some States
have less expensive plans than others. You can buy your auto insurance
across State lines. Why shouldn't we be able to buy our health
insurance across State lines?
Mr. CRAPO. If I could interrupt, my understanding is, the Republican
bill in the House, which has both ideas in it and which was evaluated,
what it would do to the cost of health care and health care insurance
premiums, that those ideas would actually reduce health care premiums
by, I think, 5 or 6 or 8 percent. I don't remember the exact number,
but the point is, those ideas would hit the reason Americans want
health care reform; that is, reduce the cost of health care coverage.
Mr. ENSIGN. I am glad the Senator from Idaho made that point, because
the No. 1 problem with health care in the United States is not quality.
We have the finest quality system--by almost any measure, the finest
quality health care system in the entire world. The problem is that it
is too expensive. We should be going after costs. This bill does not do
that. This bill actually raises premiums for tens of millions of
Americans. That isn't the direction we should be taking health care.
Another idea the vast majority of people on this side have supported
is medical liability reform. Once again, in the Finance Committee, we
asked the question--I, personally, asked the question of the CBO
Director: How much money would medical liability reform--the common one
I offered and Senator Hatch offered--how much would that save between
the government and the private sector? He said: Over $100 billion.
Well, that is not chump change; that is a significant amount of money,
$100 billion. Add that to buying across State lines, add that to small
business health plans, add that to incentivizing healthy behaviors--add
that to the elimination of preexisting conditions. I think Republicans
and Democrats alike agree, if you have insurance and you have played by
the rules and you get a disease, your insurance should not be taken
away or denied. We should eliminate preexisting conditions for those
that have played by the rules. We shouldn't allow insurance companies
to unexplainably increase rates. We should take a step-by-step,
incremental approach to health care reform instead of gutting Medicare,
as the Senator from Idaho has talked about, to create a new government
entitlement program. That is what we are saying on this side of the
aisle. However, it seems to be falling on deaf ears on the other side
of the aisle.
Mr. CRAPO. I know my colleague from Mississippi wants to make a
comment or two, but may I ask, Mr. President, how much time remains for
our side?
The PRESIDING OFFICER. There is 7\1/2\ minutes.
Mr. WICKER. Mr. President, if I could just maybe take 1 minute of
that time and then y colleagues can wrap it up.
I wish to emphasize what a devastating effect these Medicare cuts are
going to have on rural America. Once again, I wish to quote some of my
colleagues from the other end of the building because it shows the
bipartisan opposition we have against these cuts from rural America.
Mike Ross, a Democrat from Arkansas, said:

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

Representative Larry Kissell of North Carolina:

From the day I announced my candidacy for this office, I
promised to protect Medicare.

So he voted no on the bill in the House of Representatives.
Ike Skelton said:

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

Finally, Representative Boucher, a senior Democrat from Virginia,
said:

The plan could place at risk the survival of our regions'
hospitals.

Unless these Medicare changes are taken out of the bill, this bill
devastates health care for senior citizens in rural America.
I thank my colleague for yielding me the time.
Mr. CRAPO. Thank you very much. I wish to use the remainder of our
time to speak for a minute about what this bill does to different costs
in our country. I think the point we made in this colloquy is, after
the votes we just took, let no one be confused; the $464 billion of
cuts to Medicare remain in the bill.
Let's talk about the question of the cost curve. There has been a lot
of talk about what has become known as the cost curve. It has been said
by everybody we need to bend the cost curve down. Some are saying this
bill bends the cost curve down. Well, which cost curve are they talking
about? Are they talking about the size of government, the growth of
government? No. If you take the first full 10 years of the growth of
spending in this bill--which, by the way, is delayed for 4 years--if
you start when the spending starts and take the first full year, 10
years of spending, the new spending, the growth of government is about
$2.5 trillion. I don't see how anybody could say that cost curve is
bending down. It has skyrocketed.
Well, would it be the cost of health care, which I think is the cost
curve Americans were thinking about, health care insurance and the
quality of health care that is provided? Well, CBO just came out with
its report that analyzed that issue and there are a number of
independent groups that have analyzed it and they all pretty much say
it is not going to reduce the cost of health insurance. It is not going
to reduce the cost of health care. In fact, for

[[Page S12297]]

the neediest in America, those who are in the individual market, it
will drive up the cost of their insurance and not by just a little bit,
by around 10 to 13 percent. For those in the small group area, it will
drive up theirs--not as much--by about 1 to 3 percent. For those in the
large group area, there is a possibility that theirs might taper off a
little bit; the estimate is somewhere between zero impact and 2 percent
reduction.
But is that what we are talking about in America, 30 percent of the
people in this country seeing their health care insurance costs go up
and the rest seeing theirs remain basically stable? That is not the
cost curve reduction I thought Americans were talking about in health
care reform.
So then what other cost curve could they be talking about? Well,
there is a lot of talk about the deficit. Sometimes they try to shift
away from the cost of health care to the cost of the bill to the people
of America, and they say the deficit is reduced. Well, how can you say
that? There is only one way you can say that and that is if you accept
the budget gimmicks in the bill. If you raise taxes by around $500
billion and if you cut Medicare by $464 billion, then you can say this
massive expansion of government is somehow covered and that the deficit
won't grow.
Well, I think we have talked about the Medicare cuts part of this. We
are going to talk about the tax increases, which are hundreds of
billions of dollars of new taxes in the future, but what did I mean
when I said you can only say the deficit goes down if you accept the
budget gimmicks?
This bill starts the collection of revenues and the cuts out at the
front end but doesn't start the spending for 4 years, so you have 10
years--in the 10-year window we are looking at, we have 10 years of
revenue and 6 years, basically, of spending. Sure, if you only count 6
years of the spending side of the bill against 10 years of its
collection side, you are going to be able to make that deficit look a
little better.
In addition, there are major expenditures we all know are going to
have to be done in health care, such as the SGR fix for physician
compensation in Medicare, that are not even in the bill, an expense we
know over 10 years is around 200 billion to 250 billion of extra
dollars; simply not there, not counted. Well, if you want to show a
deficit reduction, you certainly want to leave out of your bill a lot
of the spending you are going to do in the future. It is gimmicks such
as these, it is tax increases, and it is Medicare cuts that allow one
to say the deficit goes down.
In conclusion, the reality is, this bill will increase the growth of
government by $2.5 trillion for a full 10-year measure, increase taxes
by hundreds of billions of dollars, cut Medicare by hundreds of
billions of dollars, create a Federal insurance company, create massive
Federal controls over the health care economy, push the neediest of the
uninsured not into an insurance policy but into a failing Medicare
system, and push an unfunded mandate of tens of billions of dollars
onto our States. That is not the kind of health care reform we need. As
my colleague from Nevada indicated, there are reforms that do make a
difference that will reduce the cost of health care, that will cut down
the spiraling costs of health care insurance, and will not require us
to have such an intrusion of the Federal Government into the management
of our economy.
It is time for us to slow down and start, step by step, to address
the kinds of reforms that will reduce the cost of insurance and the
cost of health care and that will help us to increase access to quality
care in America. We can do it, and we have a number of very good ideas
on the table we will be exploring in greater detail in future days as
well that will help us to do it.
With that, I reserve the balance of our time.
May I ask how much time remains?
The PRESIDING OFFICER (Mrs. Shaheen). The minority has no time.
Mr. CRAPO. I thank the Chair.
The PRESIDING OFFICER. The Senator from Montana.
Mr. BAUCUS. Madam President, I think it would be instructive to stop
all this rhetorical talking past each other on Medicare Advantage and
explain a little bit about how we got to where we are in this
legislation.
I don't know the exact year, but I think it was back in the 1980s
sometime, up to a certain point Medicare was basically paid fees for
services. That is the basic Medicare model. The service was provided
and there are certain set rates for that service. Then, in the 1980s,
private companies thought maybe they could be more efficient, private
insurance companies. So they came to Congress and said: We can do a
better job in compensating Medicare based on fee for service, so let's
set up something called Medicare Advantage, private entities.
So Congress said: OK, competition is a good thing. So we did that.
Congress did that. We basically set the rates to be paid to Medicare
Advantage plans at 95 percent of fee for service. After all, the plan
said they could do it more cheaply and they could compete. So we said:
OK, that sounds like a good idea. We will pay you 95 percent of what
otherwise would be paid under fee for service. That continued for a
while.
In 1997, the plan said: Gee, we need a little more money. So Congress
said: All right. And we gave a little more money to Medicare Advantage
and basically said, OK, that will pay the 95 percent. But if you are
not doing so well and making money at 95, we will set kind of a higher
floor, according to certain areas of the country, and you could choose
whatever enables you to have the greatest compensation.
The big change occurred in 2003, in the Medicare Modernization Act,
otherwise known as the drug bill. It was the legislation that created
drug benefits for seniors. As we all know, frankly, when Medicare was
created, it didn't have an outpatient drug benefit because drugs
weren't comparatively as important then as they are today. Today there
are miracle drugs that help in a lot of ways. We created the drug
benefit in 2003.
The Congress did something else then. Many Members of Congress were
concerned that Medicare Advantage might not offer the plans in rural
parts of America, that there wouldn't be enough incentive for Medicare
Advantage to go to rural America to offer the drug benefits--not only
the drug benefits but other benefits they provided. Congress, frankly,
gave a lot of money to Medicare Advantage plans so there could be at
least two plans operating in all parts of the country. Give them enough
money and they will go; that was the theory. Guess what happened. We
gave them a lot of money and they went.
We have reached the point now where Medicare Advantage is, by
everybody's estimate, quite dramatically overpaid, as the Senator from
Oklahoma, Mr. Coburn, said when I asked him yesterday whether Medicare
Advantage plans are overpaid. He said, ``Yes, they are definitely
overpaid.''
MedPAC, which advises us on Medicare reimbursement, said to us that
we are way overpaying Medicare Advantage plans. I hear figures of from
14 to 18 percent overpayment. It depends on what part of the country
you are in. Let's be conservative and say it is 14 percent in fee for
service, that they are overpaid. MedPAC is an independent advisory
group that helps us figure out what in the world we pay hospitals,
nursing homes, home health agencies, etc. We are not the experts. We
need help. MedPAC said to the Congress that we are overpaying them big
time.
We decided let's figure out a way to reform the system. How about a
little competition? Right now, Medicare Advantage plans are paid what
is called a benchmark, depending upon the fee for service in their
certain area. We all know fee for service is much less in rural
America, and I am sure in the home State of the occupant of the chair.
Fee for service is much higher in other more urban States and so forth.
As it turned out, under the benchmarks for fee for service, they were
way overpaying in States where fee for service is so high, and not
quite as much overpaid where fee for service is so low. That is a nutty
system in the current law today.
What we are doing in this legislation is, basically, we are saying:
Look, let's introduce a little competition. We are saying: Let's get
rid of the benchmark-type fee for service. It is out of whack in
different parts of the country. What are we going to do? We say: OK, we
will divide the country into geographic areas. In your area, wherever
you might be, Uncle Sam--or Medicare--will pay the average competitive
bid

[[Page S12298]]

for that area. The average cost you bid for that area is what we are
going to pay, which eliminates this big disparity between States and
makes it much more fair so that reimbursement is based much more on
what it actually costs in a certain area, but it is competitively bid.
That is what we are trying to do.
Is that a good thing to do? I think most of us think so. Is it
perfect? I don't know for sure, but we are trying our best to make this
a better system, a better program than we currently have. As a
consequence, we are going to save some money, and there will be
competition. Most of us think competition is often a pretty good thing.
That is what this is, I remind my colleagues. As a consequence, we are
not going to be overpaying Medicare Advantage plans anymore. The amount
we reduced the payment to is in line with what MedPAC says we should
pay, the Medicare Payment Advisory Commission.
We are trying to be responsible and reasonable with taxpayer money,
seniors who pay into Medicare. The point is often made that, gee, this
will hurt Medicare Advantage, hospitals, and so forth. I think it is
worth reminding all of us that a meeting occurred at the White House, I
think, 4 to 6 months ago, when all of the so-called providers--the
hospitals, insurance companies, including Medicare Advantage plans--all
got together with the President and said: Mr. President, we agree this
country needs health care reform. They all agreed.
Let's move back in history a little bit. When President Clinton
attempted health care reform, all those groups were opposed to health
care reform. This time, they are pretty much in favor of it because
they know if we don't fix it, it is going to collapse.
Back to that meeting. What did they say? They said: Mr. President, we
have all gotten together and we think we can contribute. We can cut
collectively $2 trillion in payments that go to us over the next 10
years.
That is what they said. That is pretty interesting. Thank you very
much. So we are working together to get health care reform.
Why do you think they would agree to $2 trillion? They got their
calculators out and got their financial officers together and said:
Gee, if everybody has health care--remember, 46 million Americans don't
have health insurance--if everybody had health insurance, hospitals,
Medicare Advantage plans said: Hey, we can make some money because
everybody has health insurance.
So that was the deal. They will have a little lower margins, but they
will make it up on volume. That is why they said to the President: We
can cut $2 trillion that otherwise would be reimbursements to us.
In this legislation, did we reduce the rate of increase over 10 years
by $2 trillion? No. Did we decrease the rate of increase in
expenditures by half of that or $1 trillion? No. Do we reduce the rate
of increase of health care expenditures down to, say, $450 billion,
close to $500 billion? Yes, that is what we did. About one-quarter of
the industry said they could voluntarily contribute. Are they squawking
today? No. Why? Because they got a pretty good deal. They know they can
continue to provide services and the hospitals are going to do well and
home health care agencies will do well. I will add that the profit
margin for home health agencies is about 17 percent. That is pretty
good. So we are cutting them a little bit. The profit margin for
nursing homes--Medicare payments to nursing homes--is about 15 percent.
We are cutting that a little bit. But they are still making money and
still will do well. In fact, their average rate of growth over the next
10 years is going to be in excess of 5 percent a year. Wall Street
analysts say these outfits are doing pretty well. You don't see their
stocks going down.
We are trying to do what is right and to reform Medicare Advantage,
as I just outlined it. It is a pretty fair attempt at reform. Also, we
will reduce payments to hospitals and other providers in an amount that
they can live with--not be happy with but an amount they are OK with,
and where they know they can still make money. That extends the
solvency of the Medicare trust fund another 5 years because those
providers are not being paid as much as they would otherwise be paid.
I hear Senators crying crocodile tears about how seniors are going to
be cut, and so forth. Frankly, with the changes we made, I think it is
very fair, and it will extend the solvency of the trust fund. There is
not one dime of guaranteed Medicare benefits that will be cut--not one
thin dime--in this legislation. It is true that because Medicare
Advantage--the rate of growth of increase in Medicare Advantage plans
is trimmed back a little, perhaps there will not be as many extra
benefits--not the guaranteed benefits but extras, fringe benefits, like
gym memberships and things like that. Don't forget, that is not because
that is a decision made by Medicare or by Congress; that is a decision
made by the executive offices of these private companies. I am not
saying they should do this. They could trim salaries, overhead, and
they could have a little less return to stockholders, and they could
cut down administrative costs. There are various things they could do,
which doesn't have to be passed on to reductions in fringes. Let's keep
things in perspective as to what is actually going on.

Mr. DODD. If my colleague will yield, I appreciate what the Senator
has just done. This is an area where I think there is a lot of
confusion and misunderstanding. A lot of it begins with just the
branding, the title of something. This was, frankly, a revelation to
me, going back a number of weeks ago. I heard the words ``Medicare
Advantage.'' I thought this has to be part of the regular Medicare
Program because it has that title.
Mr. BAUCUS. Most people did.
Mr. DODD. If my colleague will correct me if I am wrong, this is not
traditional Medicare; this is a private plan, right?
Mr. BAUCUS. That is correct. To be totally fair, the other side likes
to trot out this Medicare pamphlet that includes Medicare Advantage. I
think that is misleading and not accurate. As the Senator says, these
are private plans.
Mr. DODD. In looking back a few years ago, the original reason--and I
don't recall the debate as well as my colleague, the chairman of the
Finance Committee, does. As I remember, the original idea behind this
was--and he said this already, but it deserves being repeated--this was
a way of cutting costs, reducing expenditures. In a sense, we were sold
this idea on the fact that we could do this better, more efficiently,
at far less cost.
Mr. BAUCUS. Absolutely. That was the rationale.
Mr. DODD. That is why we supported trying this idea. A couple of
things happened since then. One, I think the overpayments, on average,
are around 14 percent.
Mr. BAUCUS. That is correct. It depends on the part of the country.
Mr. DODD. So, on average, it is 14 percent in overpayment. Is it also
true that roughly 80 percent of Medicare beneficiaries don't get any of
these benefits?
Mr. BAUCUS. That is correct.
Mr. DODD. And that the average Medicare couple over the age of 65 is
paying, I am told, about $90 a year more in Medicare payments for
benefits they don't get.
Mr. BAUCUS. Exactly.
Mr. DODD. So here we have 75 to 80 percent of the beneficiaries of
Medicare paying more money and not getting the benefits for a program
that costs more than 14 percent more, and it is a private plan.
Mr. BAUCUS. With great considerable administrative costs and profits
that otherwise could go to seniors.
Mr. DODD. Our bill does something that I think our friend from
Oklahoma, Senator Coburn, pointed out that is absolutely critical,
which is that competitive bidding did not exist in the original.
Who was setting these rates originally during this period of time?
How did these rates get set? Did Congress set them?
Mr. BAUCUS. Congress did. Congress set the benchmarks.
Mr. DODD. Is it true that if these Medicare Advantage plans come in
under the benchmark bid, they actually get a piece of the savings? Is
that correct as well?
Mr. BAUCUS. That is correct.
Mr. DODD. So there is an incentive to trim the cost of the
administration of the program. It is also true the plans get bonus
payments for care, coordination, and quality, and plans can use these
bonuses to improve benefits?

[[Page S12299]]

Mr. BAUCUS. That is correct. Under this legislation, we say--frankly,
under the earlier Medicare Advantage plans, HMOs had some coordinated
care, but the other half, the private fee for service, preferred
provider organizations did not have coordinated care.
We are saying in the legislation that if you are in the Medicare
Advantage plan, which includes a whole list, and you provide
coordinated care, we are going to give you a bonus.
Mr. WICKER. Madam President, will my friend yield for a question?
Mr. DODD. Certainly.
Mr. WICKER. I realize we do not have much time. I have a quick
question. I was listening to the debate on television. I understood the
Senator to say Medicare Advantage is not part of Medicare. My question
is: I have here the Medicare handbook for 2010, ``Medicare and You.''
It says right on page 50:

Medicare Advantage Plans (Part C). A Medicare Advantage
plan . . . is another health coverage choice you may have as
part of Medicare.

My question to the Senator is--to my friends on the other side of the
aisle: Is the Medicare handbook inaccurate and, if so, will you be
calling CMS, Medicare, and be asking them to change what they say
explicitly on page 50 of the Medicare handbook?
Mr. BAUCUS. That is a very interesting question. When I was told
about the handbook, that is what I thought I was going to do, is call
up Medicare and say that is misleading and it is inaccurate because it
is misleading and it is inaccurate.
Mr. DODD. Absolutely.
Mr. BAUCUS. These are private companies.
Mr. WICKER. Even though Medicare put it in their handbook, has had it
for several years, it is wrong?
Mr. DODD. They are wrong. It is a private health care plan. It is a
private health care plan. Medicare is a public plan. Medicare Advantage
is not Medicare, and it is certainly not an advantage, given the
overpayments that occurred.
Mr. WICKER. Isn't it in part of the Medicare legislation?
Mr. DODD. It is a private plan. My colleague understands that, I
hope. Medicare Advantage is a private plan. You know that, of course,
don't you? I assume you know that.
Mr. BAUCUS. It has officers, a board of directors.
Mr. WICKER. I know this. It is in the handbook. I want my two friends
of the majority party to get it out of there. We thought all along it
is part of Medicare and the millions of senior citizens who rely on
this and who were told in the campaign, if you are satisfied with your
coverage, you don't have a thing to worry about, they are going to be
able to keep their coverage. Under the Democratic legislation, they
would not be allowed to keep their coverage under this bill.
Mr. DODD. If I can reclaim my time, 80 percent of older Americans are
paying $90 more a year for this. Do they have any say in this? They
don't get any of the benefits. Why are they writing a check for $90 a
year to pay a private plan from which they get no benefits? What about
them? Don't they deserve something in all this?
Mr. WICKER. The question I had was: Is this a part of Medicare?
Mr. DODD. It is not.
Mr. WICKER. I realize my friends have a difference of opinion. The
authorities for Medicare who put this publication out year after year
say Medicare Advantage is part of Medicare. It is Part C. I think it is
disingenuous for my friends to say it is not.
Mr. DODD. The only reason it is part of it is it is subsidized. This
plan gets subsidized by the American taxpayers. That is the only
qualification that puts it under the Medicare umbrella because our
taxpayers are writing a check to a private company. That is why it gets
included as part of Medicare. Other than that, it is a private plan.
Mr. BAUCUS. This is a semantic question. When you see the operational
effects, as my good friend from Connecticut said----
Mr. WICKER. One other question. Is it a semantic question to ask: Are
the American seniors who are currently enjoying Medicare Advantage
going to be disallowed from this program? The answer is yes, under this
bill.
Mr. BAUCUS. This legislation, if I may say, expressly states there
will be no reduction in what is called guaranteed benefits under
Medicare. No reduction, whether it is under Medicare Advantage, whether
it is under fee for service--whatever it is, no reduction whatsoever.
To be fair to my good friend, I used the words ``guaranteed
benefits.'' Guaranteed benefits are the usual benefits seniors think of
when they are under Medicare. They go to a doctor, hospital, so on.
We have given, unfortunately, so many additional dollars to the so-
called Medicare Advantage plans--way above what they should have
received. MedPAC agrees. Senator Coburn totally agrees they have been
paid way too much. They have taken advantage of that advantage by
giving additional benefits, in addition to the guaranteed benefits.
Those additionals are things such as gym memberships--a lot of extra
stuff that, frankly, is not part of Medicare, is not directly related
to health.
I might say, too--I have said this a couple, three times and I will
say it again--a reduction in the increase of payments to Medicare
Advantage, the effect of those reductions is a decision made by the
officers of that company. They could take those reductions and apply
them anywhere. They could reduce their salaries. They could reduce
their admin costs. They could take other actions that would reduce the
rate of growth, the rate of return of their stockholders. They do not
have to take it out of the beneficiaries. That is their choice. They do
not have to.

Mr. DODD. Medicare Advantage decides how to use their extra payments
to provide benefits. They decide; Congress does not. There is nothing
in the legislation that forces plans to reduce benefits at all, rather
than reducing profits.
Medicare Advantage is one of the profitable business lines of the
private insurance. In fact, the New York Times on November 2--just
about a month ago--reported:

Humana, the health insurer, posted on Monday a 65 percent
jump in third-quarter profits--

We are talking about private health care. These are profits, a 65-
percent jump in profits off this plan--

as bulging membership and premiums from Medicare Advantage
overcame a lackluster commercial segment.

I appreciate the fact that people are getting eyeglasses and things.
That is wonderful. But we need to be clear about this. These are not
the guaranteed benefits, and 80 percent of Medicare beneficiaries get
none of these advantages and yet pay more so other people under this
private health care plan--because it is subsidized by the American
taxpayers--get them.
Again, now we are going to put competitive bidding in place. Our bill
allows, under these plans, if they follow and do some of the
incentives, to actually share in some of the profits. We are not
talking about eliminating all of this plan. We are trying to make it
work better for people under the bill.
We have to be honest what we are talking about. This is a private
insurance company that is subsidized by the American taxpayers. It is
not what, traditionally, people think of Medicare.
Mr. WICKER. Will the Senator yield?
Mr. DODD. I will be happy to yield.
Mr. WICKER. The chairman, when he is calling HHS to change the
handbook, also needs to tell them to change their Web site, where it
says Medicare Advantage is part of Medicare.
Can the Senator from Connecticut guarantee that under this
legislation, the benefits to Medicare Advantage recipients will not be
cut? Can he make this guarantee?
Mr. DODD. What I wish to say and what I wish to ask my colleague--
Mr. WICKER. The reason he cannot make this guarantee--
Mr. DODD. Let me claim my time. There is not a single guaranteed
benefit under Medicare that is cut in this bill. Not one. I defy any
Member of this body to identify a guaranteed benefit under Medicare
that gets cut. You cannot find one. Do we cut out gym memberships and
things such as that? Yes, that may happen. But on the guaranteed
benefits--operative word is ``guaranteed''--under guaranteed benefits,
there is not a single cut to a benefit. That is why an organization
representing 40 million Americans that endorsed the Bush prescription
drug plan, by the way, in 2003--hardly a partisan organization as some
have suggested today--has basically opposed

[[Page S12300]]

the McCain motion and has endorsed the legislation before us today.
That organization, I say to my good friend, would never be endorsing a
bill that was going to cut guaranteed benefits under Medicare.
Mr. BAUCUS. I wish to say something else to put this in perspective.
That is according to analysis of Medicare Advantage plans from
Oppenheimer Capital Fund, dated November 12 of this year, between 2006
and 2009. Their estimate is, Medicare Advantage accounted for nearly 75
percent of the increase in gross profits among the larger Medicare
plans in the industry.
Let me say this:

. . . Medicare Advantage . . . has been a huge driver--

Quoting from the Oppenheimer Capital Fund--

a huge driver of earnings growth for the industry in recent
years. Between 2006 and 2009, we estimate that Medicare
Advantage accounted for nearly 75 percent of the increase in
gross profits among the larger plans in the industry,
highlighted by an estimated gross profit increase of $1.9
billion in 2009, relative to commercial risk earnings gains--

That is basic health insurance, not Medicare Advantage plans but
basic health insurance--

of nearly $600 million. Medicare Advantage probably won't be
as much of a contributor in 2009--

But it is going to be a very large contributor in 2009 because of
advantages they get.
Mr. WICKER. It is clear the Senator does not like Medicare Advantage.
It is also clear no guarantee can be made that Medicare Advantage
benefits will not be cut under this legislation. It is also clear there
are tens and tens of millions of American senior citizens who like
their Medicare Advantage, notwithstanding the Senator from Montana, and
they stand to lose those benefits under this legislation.
Mr. DODD. Let me point out, one of the things we have not talked
about, I say to my friend from Mississippi, under our legislation, this
bill protects seniors in Medicare Advantage from plans that care more
about profits than seniors, trying to pass the buck. Under our bill, it
allows the Secretary of Health and Human Services to kick out any plan
under Medicare Advantage that significantly increases their premiums or
decreases their benefits. Under existing law, that would not happen;
under our bill, it does.
It is not about being hostile to Medicare Advantage. It is being
realistic about all this and trying to make the tough decisions we have
to make about trying to stabilize Medicare, seeing to it we are going
to have protections in premium reductions and cost savings, as well as
increasing access and quality.
All we are trying to point out is, when you have a Medicare Advantage
plan that has run as poorly as this one has, at great cost we now
learned--14 percent above, on average; some places it is 50 percent
above average--where is the equity. By the way, I say to my friend from
Mississippi, it is a private health care plan that receives subsidies
from the American taxpayers, where 80 percent of seniors today pay more
and get nothing for it. Where is the equity in this? There is no equity
in this. Why should 80 percent of that population pay $90 or more a
year, on average, for a benefit they don't get? Where is the equity?
Mr. BAUCUS. I might add, too, to remind us all, this legislation
provides additional benefits for all seniors, including Medicare
Advantage recipients--additional benefits. What are they? No copayment
for certain preventive care--mammograms, for example, colonoscopies,
screening benefits that are not in existence today. There are a whole
host of other things that are additional.
This legislation provides additional benefits to Medicare Advantage
members that are not there today.
When I say ``guaranteed benefits,'' I am talking about the usual
benefits seniors think of under Medicare. It is hospital care, it is
nurses, it is all medically necessary physician care, diagnostic
testing, supplies. It is home health care, preventive care, skilled
nursing, hospice--all the things that are basically related to health
care.
The only thing that might be trimmed back a little is, I call them
the fringe stuff, the excesses, such as gym memberships. I wish I had
the whole list because some of them are not related.
As I said earlier, they may not be cut. They don't have to be. It is
up to the private companies whether to cut. I have nothing against
companies making profits. They should make profits. It is our
responsibility as Senators to make sure the reimbursement rates
Medicare pays providers are fair and reasonable and not excessive. We
have been told they are excessive. So we are trying to find a way to
make it fairer.
Mr. WICKER. This segment of debate will end at the bottom of the
hour, so it is almost over. I appreciate my friends yielding. This
debate will continue for days, weeks. I say to my friends, there are
Members on their side of the aisle who have come before this body and
said these Medicare Advantage cuts are unacceptable. I think they are
going to have to have a lot of convincing too. Democratic Members of
the House have also come forward. I am not convinced. I don't think
they are convinced.
The PRESIDING OFFICER. All time has expired.
Mr. DODD. Madam President, I ask unanimous consent for 2 additional
minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. DODD. Madam President, let me say to my colleague again that here
we have two organizations representing 43 million seniors in our
country, and these are organizations that don't just write letters on
the fly. They have staffs that examine proposals here, and that is all
they do. We have AARP, which is an organization that is highly regarded
and well recognized, representing 40 million seniors in the country,
and the Commission to Preserve Social Security and Medicare, which
represents an additional 3 million, and that is all they do. This is a
totally nonpartisan examination. These two organizations, representing
almost 50 million of our seniors, have examined this bill in detail--
every dotted ``I,'' every semicolon, every comma, every proposal--and
have done exhaustive research, and they have said: This is a good bill.
This bill is deserving of support.
We received a letter today from them. They are not Democrats. They
are not Republicans. They are not trying to get an advantage over
anybody. They are examining whether this bill stabilizes and
strengthens Medicare, puts seniors in a stronger position, is going to
see to it that we can extend the life of the program and provide
guaranteed benefits that are needed, and their answer was a resounding
yes--yes, this bill is deserving of our support.
Again, I appreciate the political debate here, but at some point we
have to step back and let those whose job it is to analyze our
suggestions and our ideas--just as AARP supported President Bush 6
years ago with his prescription drug bill. They didn't join Democrats
or Republicans; they liked the idea--still do--and supported it. Today,
they are not supporting us as Democrats. They would reject this bill
out of hand if they thought we did something adverse to the interest of
their membership. But they said: No, this is a good bill, deserving of
support. The two largest organizations in this country representing
seniors have said: Get behind this bill. Let's support our seniors.
Let's make Medicare stronger and strengthen it. And this bill does it.
That is why we should be joining together, not fighting over this.
Medicare Advantage is a private health care plan subsidized by the
American taxpayer. Eighty percent of the seniors don't get the
Advantage. That is why we are creating these changes in this bill.
I applaud my colleague from Montana, the chairman of the Finance
Committee, who did incredible work, along with his staff and other
members, in producing this product.

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