To permit continued financing of Government operations.

Madam Speaker, by direction of the Committee on Rules, I call up House Resolution 976 and ask for its immediate consideration.

Madam Speaker, I claim time in opposition.

Madam Speaker, I yield myself such time as I may consume.

Madam Speaker, as my colleagues know, we have been here before. This is the same point of order that has been raised against almost every appropriations measure during this Congress, and each time it is used to discuss something other than its intended purpose.

I would want to respond to my good colleague from Arizona that I, too, share concerns about the earmarking process, and I encourage him to become a cosponsor on the fair elections bill. As we have in Maine, public financing takes away much of the scrutiny around the link between campaign contributions and earmarks.

But once again, this particular debate is about delaying consideration of this bill and ultimately stopping it altogether. I hope my colleagues will again vote ``yes'' so we can consider this important legislation on its merits and not stop it on a procedural motion.

This rule provides for enactment of legislation to fund our Nation's defense. The brave men and women who serve in the military, particularly those who are currently at war in Iraq and Afghanistan, deserve a swift enactment of this legislation.

This legislation that we will take up later today will also divert TARP money to programs that create and save jobs across the country. We do this by investing $75 billion of TARP money into highways, transit, school renovation, hiring teachers, police, firefighters, supporting our small businesses, funding job training, and affordable housing. And for those hardest hit by the recession, this bill also provides emergency relief by extending programs like unemployment benefits, COBRA, FMAP, our health care funding for the State, and the child care tax credit.

Those who oppose this measure can vote against it on final passage. We must consider this rule, and we must pass this critical legislation today.

I have the right to close, but in the end I will urge my colleagues to vote ``yes'' and consider the rule.

Madam Speaker, I reserve the balance of my time.

Madam Speaker, again I want to urge my colleagues to vote ``yes'' on this motion to consider so that we can debate and pass this and the other important items covered by this rule.

Madam Speaker, I yield back the balance of my time.

Madam Speaker, for the purpose of debate only, I yield the customary 30 minutes to the gentlewoman from North Carolina, Dr. Foxx. All time yielded during consideration of the rule is for debate only.

General Leave

I ask unanimous consent that all Members be given 5 legislative days in which to revise and extend their remarks on House Resolution 976.

Madam Speaker, I yield myself such time as I may consume.

Madam Speaker, House Resolution 976 provides for the consideration of the Senate amendment to H.R. 3326, House Joint Resolution 64, H.R. 4314, and the Senate amendment to H.R. 2847.

For the Senate amendment to H.R. 3326, the rule makes in order a motion to concur in the Senate amendment with the House amendment, provides 1 hour of debate controlled by the Committee on Appropriations, and waives

all points of order against consideration of the motion except those arising under clause 10 of rule XI.

The rule provides for consideration of H.J. Res. 64 under a closed rule. It provides for 1 hour of debate controlled by the Committee on Appropriations. It provides one motion to recommit with or without instructions. It waives all points of order against consideration of the joint resolution except those arising under clause 9 or 10 of rule XXI, and it waives all points of order against provisions in the joint resolution.

The rule provides for consideration of H.R. 4314 under a closed rule. It provides for 1 hour of debate controlled by the Committee on Ways and Means. It provides one motion to recommit with or without instructions. It waives all points of order against consideration of the bill except those arising under clause 9 or 10 of rule XXI, and it waives all points of order against provisions in the bill.

For the Senate amendment to H.R. 2847, the rule makes in order a motion to concur in the Senate amendment with the House amendment. It provides 1 hour of debate on the motion controlled by the Committee on Appropriations, and it waives all points of order against consideration of the motion except those arising under clause 10 of rule XXI.

The rule provides that in the engrossment of the House amendment to the Senate amendment to H.R. 2847, the Clerk shall add the text of H.R. 2920 as passed by the House.

The rule also provides that measures may be considered under suspension of the rules at any time during the remainder of the first session of the 111th Congress.

The rule waives the requirement of a two-thirds vote to consider a rule on the same day it is reported from the Rules Committee for the remainder of the first session of the 111th Congress.

The rule provides that the Chair of the Committee on Appropriations may insert in the Congressional Record explanatory materials on the Senate amendments and the motions regarding H.R. 3326 and H.R. 2847.

The rule provides that, on any legislative day before January 12, 2010, the Speaker may dispense with organizational or legislative business.

The rule provides that, before January 12, 2010, the Chair may declare the House adjourned.

The rule provides for pro forma sessions until the House adjourns sine die.

And finally, the rule provides that, on any legislative day of the first session of the 111th Congress, the Speaker may declare the House adjourned.

Madam Speaker, the rule before us today allows the House to consider the Department of Defense Appropriations Act for fiscal year 2010, which is the last appropriations bill for this fiscal year.

The conference agreement on H.R. 3326 provides over $363 billion towards protecting our troops abroad and taking better care of their families at home. To help protect our troops, this bill provides increased funding for the Mine Resistant Ambush Protected Vehicle Fund and for the procurement of new Humvees and of new heavy and medium tactical vehicles. This is particularly important given the casualty rate and the difficulties our soldiers are experiencing in Afghanistan.

H.R. 3326 increases pay for all servicemembers by 3.4 percent, and it fully funds the requested end strength levels for active reserve and selected reserve personnel. The bill provides over $29 billion for top- of-the-line medical care, including $120 million for traumatic brain injury and psychological health, and it increases funding for the wounded, the ill and injured warrior programs.

The conference agreement also includes over $472 million for family advocacy programs, and it fully funds the family support and yellow ribbon programs. The bill also includes $20 million for the Army National Guard family assistance centers and reintegration programs; but this bill cannot provide for the common defense without a common effort.

In my home State of Maine, there are men and women who work every day to help in this effort. The funding in this bill would have been wasted if it weren't for the efforts of the welders, designers, and metal workers of the Bath Ironworks; of the skilled factory workers and assembly men at Vintech in Biddeford, Maine; of the world-class machinists and engineers at Pratt and Whitney in North Berwick; or of the dedicated laborers and nuclear engineers at the Portsmouth Naval Shipyard.

This is a clear example of why the bills before us today are so interconnected. Our economic security and our national security are inextricably linked, and our economic security is still in dire straits.

Madam Speaker, if you were sitting at a boardroom table on Wall Street today, you might hear the employees with Goldman Sachs discussing their $1 billion in profits or bonuses or you might hear employees of Citibank discussing raises for their top executives. You might also hear that the stock market has gone up 60 percent since the spring. You might even hear terms like ``economic recovery'' or ``rebound.'' So, if you are sitting at that boardroom table on Wall Street, you might think that the economy has fully bounced back and that we are out of the woods. You may start to believe that there is nothing but smooth sailing ahead.

Yet, if you were at a kitchen table on Main Street in my home State of Maine, you would hear a very different story. Rather than talk of large profits, you would hear families discussing a savings account that has all but disappeared. Instead of listening to talk of raises or bonuses, you would hear families debating cutbacks on food or cutbacks on health care. Instead of hearing phrases like ``economic recovery'' or ``rebound,'' you would hear terms like ``high unemployment'' and ``mounting debt.''

For the big banks on Wall Street, the economic recovery may be at hand, but for the millions of unemployed workers and for the thousands of small businesses that are struggling to get by, the economic recovery is still a long way off. In my State and all across the country, there are millions of Americans who want to get back to work, but they need us to lend the same helping hand that we gave to Wall Street in its time of need.

Madam Speaker, the rule before us today allows for the consideration of the Jobs for Main Street Act, which will move us down that road. This legislation invests in our Nation's infrastructure, and it puts more Americans back to work by providing $48 billion to rebuild and repair our national transportation system. This investment provides a measurable return, not only by creating and preserving jobs but by literally building the foundation for a long-term economic recovery. This bill will also preserve the jobs of teachers, of police officers, and of firefighters. For those who have already lost their jobs, the Jobs Act extends unemployment benefits for 2 months, and it maintains the current COBRA subsidy.

These programs--these investments, the economic lifelines--have a real impact. Just this week, I heard from a constituent of mine who said these words: Something needs to be done. There are less than 4 weeks left for my husband's unemployment. After that, we won't be able to pay the rent, and we will be out on the streets with a child under 2 years old. Every day, I wonder what is going to happen next, and I even have nightmares. You bail out these large banks which then only raise our interest rates and lower our credit lines--and for what? That doesn't help the little guy like us. Do something to help us.

Madam Speaker, we have the opportunity and we have the obligation to take the bailout money that was used as a lifeline to Wall Street and to give that money back to the American people and to those who have been hit the hardest by these tough economic times. The COBRA subsidy we passed this spring began expiring a few weeks ago. If we don't act now, it will completely disappear by January 1. In my State, full payment for COBRA uses up nearly 90 percent of the average unemployment benefits. That means out-of-work Mainers end up with only about $150 a month left after paying the full cost of their health insurance.

We need to act now, and we need to act fast to ensure that Main Street recovers. If we do not act, we will have only assured that Wall Street keeps

their bonuses while American families lose their benefits. We will have only watched Wall Street get rid of their debt while watching small businesses take on more.

Madam Speaker, we have already put more than enough into shoring up Wall Street. Now we need to focus on creating jobs for the average American that will rebuild our economy from the bottom up.

I reserve the balance of my time.

Madam Speaker, I yield 3 minutes to a member of the Committee on Rules, the gentleman from Massachusetts (Mr. McGovern).

Madam Speaker, I yield 3 minutes to the gentleman from New York, a member of the Committee on Rules, Mr. Arcuri.

Madam Speaker, before I yield to one of my colleagues, I do want to mention one point of concern I have in the bill.

The conference agreement on H.R. 3326 is the first step towards cutting wasteful defense spending, but it is by no means perfect. It is no means the last step that we must take. The conference agreement provides $465 million for the development of an alternative engine for the F-35 Joint Strike Fighter. This provision represents businesses as usual in Washington for providing funds for an engine that's already being built and already being built well.

There is no need to devote our precious Federal dollars to a wasteful alternative engine program at this time when Americans are struggling to find jobs to pay their medical bills and to put food on the table. Every defense bill that we spend wisely contributes to our national security, and every defense dollar that we waste hampers our economic security.

Madam Speaker, I would like to yield 2 minutes to the gentleman from Illinois (Mr. Hare).

Madam Speaker, I yield 2 minutes to the gentleman from Washington (Mr. Dicks), a member of the Committee on Appropriations.

I yield the gentleman an additional 30 seconds.

Madam Speaker, I yield 1 minute to the gentleman from Washington (Mr. Dicks).

Madam Speaker, I yield 3 minutes to the gentlewoman from Texas (Ms. Jackson-Lee).

I yield the gentlewoman 15 additional seconds.

Madam Speaker, I yield 2 minutes to the gentleman from Maryland (Mr. Cummings).

Madam Speaker, I rise to discuss at least one thing my colleague and friend from North Carolina mentioned. I'm a Northerner, so I can't claim to be an expert on crocodiles, but I assume that when you're talking about crocodile tears, you're talking about being insincere, and I want to say I receive letters from my constituents every day about the urgency of what we are doing today. And I have to say that like it or not, I cannot get through the pile of letters without crying tears for real. It's very, very difficult to think about the small businesses, laid-off individuals, individuals worrying about their jobs, what they're going through in my district and the urgency with which they view the actions that we are about to take today and the importance of moving on from this rule and getting to the actual debate.

I want to read one of them that is in front of me here before I yield a little time to my colleague from California.

This one says: ``My housemate and I were both laid off, me in September 08 and she in February 09. We have applied diligently for work in and around Portland with no luck. We had to cash in our meager 401(k)'s, and have been very thankful for the COBRA subsidy so that we could afford insurance during this most harsh of times. But our money is running out fast.

``As you know, the subsidy is about to expire, and we cannot afford the huge jump in premium. We cannot afford both the mortgage and the insurance. We cannot afford our prescriptions, and our health care will be at stake, as if things weren't bad enough. We will lose our home.

``PLEASE help push through the COBRA extension and continuation of the ARRA COBRA subsidy. It is an immediate fix for so many families who will surely gain employment over the next 6 months now that the economy has finally taken an upswing.''

Madam Speaker, those are the things that make us all cry real tears and make us want to pass this rule and go on to passing this legislation today.

Madam Speaker, I yield 2 minutes to the gentleman from California (Mr. Garamendi).

Madam Speaker, the legislation we are considering today is about investing in jobs. It is about investing in infrastructure, and it is about rebalancing our economy. So it's not just the big banks and Wall Street firms that benefit from an economic recovery. This bill is about helping the American family.

This week, a New York Times/CBS News poll surveyed unemployed Americans. Not surprisingly, they found that being unemployed takes a toll far beyond what can be measured in dollars and cents. Half of the people surveyed said they had begun to suffer from depression and anxiety, half said the recession has caused them to make major life changes, and nearly half said they have seen changes in their children's behavior that they know is a result of their difficult financial situation.

We are not just helping men and women who've lost their job, who have suffered from uncertainty, emotional pain, and indignation, but we are helping their families. We are helping their children. It is time for us to invest in the jobs and policies that will get the American Dream back on track and restore the promise of opportunity and prosperity for everyone.

I urge a ``yes'' vote on the previous question and on the rule.

I yield back the balance of my time and move the previous question on the resolution.

Mr. President, we have reached a defining moment for the Senate and for the American people. The bill we have considered will rank alongside other major decisions such as the creation of Social Security and Medicare and the Civil Rights Act. Health insurance reform has been talked about and attempted for seven decades. The American people for years have named health insurance as among the greatest concerns in their daily lives. Now, here at hand, is the opportunity to act.

This has been an arduous process. The President has rightly noted that if health insurance reform were easy, it would have been done long ago. The defenders of the status quo have spared no expense--nor have they been sparing in their distortions--to keep the system that pays them so handsomely. Health reform will benefit every American of today's generations. But let us especially think ahead one, two or three generations. If we were to abandon our responsibility now, saying it was too difficult, that would be an excuse for doing nothing that our children and grandchildren would never accept.

For many reasons, including the health of public discourse on the most pressing issues we face as Americans, it is regrettable that the defenders of the status quo, doing their utmost to influence this debate from their comfortable perches outside the Senate, have stooped to new levels to obstruct health insurance reform. Friction is a byproduct of reform, especially when well-funded and entrenched special interests rally to protect the status quo. The heat of this debate is a measure of the cozy setups that these reforms will unsettle. This year alone Senate Democrats have been forced to contend with 101 filibusters by the minority Republicans. Even on an issue this important, health insurance reform is still being subject to filibuster and parliamentary delay to a level I have not seen in 35 years in the Senate.

Opponents of reform unfortunately have wasted much of the public's time by provoking arguments over their distortions about what health reform really means. The country suffers when there is a failure to act on serious challenges that millions of ordinary Americans face in their daily lives.

The arguments that we hear today to prop up the status quo by knocking down challenges to the way things are seem eerily similar to those made against creating Medicare nearly 45 years ago. Opponents then tried to demonize the plan and claimed it would never work. During the debate decades ago on Medicare, one Senator said: ``It would achieve little for those who need it, while subjecting the very fabric of American life to the strain of severe and unnecessary sacrifices.''

Eventually during that historic debate, Members from both sides of the aisle worked together to pass a bill that is one of the most successful, purposeful and popular programs today. The Medicare Program, like Social Security, was not perfect when it began, but improvements have been made over time. Vermonters can be proud that our State's congressional delegation, all Republican at the time, supported passage of that landmark legislation.

The Senate has overcome the stalling and delay tactics, the filibusters and the roadblocks to the consideration of health care reform, and now we are closer than ever to passing comprehensive and meaningful health insurance reform.

Is the Senate health care bill without any problems? No. Is the bill before us the one I would have drafted or the one that any other Member of the Senate would have drafted? Of course not. Extensive negotiations and refinement were needed to produce a bill of this scope and importance, as it should be in the legislative process. The difficulty was magnified by the minority's calculated decision to spend their efforts to undermine, instead of to constructively engage. Not only majorities but supermajorities were required at several steps in the Senate's work on this bill. There are 100 Senators and 435 Members of the other body who will have to stand up and be counted in this historic process. The votes of most, I believe, will be tallied on the right side of history and of the real-life, everyday needs of the American people for real health insurance reform.

Some say the bill before us does not go far enough. Others say it goes too far. What everyone can agree on is what will happen if we do nothing.

In the next decade, without reform, half of all nonelderly adults will find themselves without coverage at some point. The number of people without insurance will jump by more than 30 percent in 29 States and by at least 10 percent in every State. American families will continue to pay a hidden tax of $1,100 on their health insurance premiums to pay for the costs of care for the uninsured. The very same insurance coverage a family has in 2008 is projected to nearly double to $24,291 by 2016, consuming a whopping 45 percent of projected median family incomes. Premiums will continue to double every several years, making health insurance vastly unaffordable for many Americans. Economists project that if health insurance reform fails, the resulting lower gross domestic product, GDP, will reduce family incomes by $10,000 by 2030. Small businesses will continue to struggle and fewer and fewer will be able to offer coverage to their employees.

Furthermore, as our population ages, Medicare is projected to be insolvent within 10 years, jeopardizing coverage for millions of American seniors. Each day that passes without reform, 14,000 Americans lose health insurance coverage. These are not minor problems to be brushed aside or kicked yet again down the road for another generation of Americans to tackle. These problems are on the Senate's doorstep, right here, right now. Keeping the status quo guarantees a struggling economy in the future, with more Americans unable to afford lifesaving treatments because of the rising cost of insurance.

In 2001, 46 percent of all bankruptcies were attributable to medical costs. By 2007, that number had grown to 62 percent. While hard-working Americans were losing their jobs, homes and savings simply because they got sick, insurance and pharmaceutical company executives were making record profits. In 2000, the 10 largest publicly traded health insurance companies had profits of $2.4 billion. By 2007, profits at those firms had jumped to $12.9 billion, a 428-percent increase. In 2007, CEO salaries at these firms were $118.6 million or $11.9 million for each CEO. In 2007, prescription drug companies had a profit margin of 15.8 percent. The same year, profit margins at all Fortune 500 firms were 5.7 percent.

Since the Nation's last attempt to pass health reform 16 years ago, millions of Americans have lost their insurance and costs have skyrocketed. In the absence of a fair and sensible health insurance system, families, businesses and taxpayers have been dragged along by an inflationary curve that only worsens with time. Next year, small businesses--already suffering from skyrocketing medical costs--will see their premiums rise by an average of 15 percent--twice the rate of last year's increases. Drug companies have boosted prices of brand-name drugs by about 9 percent over the last year, the steepest increase in years.

Even though Vermont has long recognized the importance of building a health care system that includes all Vermonters, individual States acting alone cannot make enough progress without comprehensive health insurance reform. Tens of thousands of Vermonters still lack basic health insurance. Workers nationwide are losing insurance for their families when they change or lose jobs. Insurance companies can and do discriminate against sick people.

I know so very many of these Vermonters. Many of them are my neighbors, my friends. Some of these Vermonters without health insurance went to school with me. Some grew up as I did in Montpelier, VT. Some are people I have known all our lives. They are hard-working, good, honest, decent people. It is a travesty that after working so hard and playing by the rules they still cannot begin to have the kind of health coverage that Federal employees--including those of us in this Chamber--are able to have because of earlier reforms of the Federal workforce health insurance system.

Too many Vermont families live in the shadow of constant insecurity because they know that if they have an illness or if they lose a job, it might mean the end of their health insurance. Too many Vermonters are forced to sell their homes or file for bankruptcy to pay their health insurance bills. In no other modern society are families confronted with such heartbreaking dilemmas.

Let me give a personal example. I heard recently from a Vermonter who only periodically had health insurance throughout his life and now goes without prevention and screenings and pays for everything out of pocket because he cannot afford any health care that is not urgently needed. Tragically, his wife was in a car accident, and even though the couple paid thousands in treatments, they ``had to stop short'' in giving her the necessary physical therapy and medications her doctors recommended because of the costs involved.

Another Vermonter, who is lucky enough to have insurance, says her family pays almost $1,100 each month in premiums, and yet they have to reach a $3,000 deductible before the insurance company will pay a dime. She told me that ``as the cost of health insurance continues to rise, it feels like we will be swallowed whole by it.''

These should not be stories heard in today's America. We remain the only

industrialized Nation in the world that lets its citizens fend for themselves without health coverage.

The bill before us would make giant leaps toward reforming our health insurance system. Under the Senate bill, 31 million more Americans would have health insurance, bringing coverage to 94 percent--the highest level of insured Americans ever in our history. More low-income Americans will be able to access the State Medicaid Programs, and middle-income families will get enough help to be able to buy health insurance through State-based health insurance exchanges, which will be closely monitored. Insurance companies will never be able to drop your coverage, charge you more, or deny you or your children coverage because of a preexisting health condition. This bill also sets standards for qualifying health insurance so the insurance companies can no longer sell you coverage that does not actually help when you are sick. The legislation also contains a Patient Bill of Rights, long championed by Senator Kennedy, which guarantees that patients have a right to appeal denials or decisions by their health insurance companies.

The insurance industry will no longer be allowed to pay excessive executive bonuses and salaries on the backs of their customers. All insurance companies will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits--or else they will have to pay rebates to policyholders. This change will improve quality of care and will hold the insurance industry accountable for their spending.

Small businesses, which make up more than 80 percent of the businesses in Vermont, at long last will have access to affordable care under this bill. This bill will make tax credits available to small businesses to help them offer health insurance to their employees. These tax credits will make health insurance more affordable both for small businesses and for their workers.

The nonpartisan Congressional Budget Office confirmed that the reforms in the bill--including lower administrative costs, increased competition, and better pooling for risk--will lower premiums for American families. CBO estimates premiums for the overall population will be reduced by 8.4 percent.

In addition to the consumer protections and industry accountability provisions, this bill also takes significant strides to slow the growth of the spiraling health spending that has the potential to cripple our economy in the years to come. A substantial portion of the Senate bill is devoted to testing ways to reduce health care costs while improving quality over time. The bill contains pilots for efforts like Vermont's Blueprint for Health, under which patient care is coordinated to reduce unnecessary hospital visits and to keep patients healthy. Other programs will test various ways to pay doctors and hospitals that could be more efficient than the current fee-for-service structure. A greater emphasis on prevention--long supported by Senators Kennedy and Harkin in the Health, Education, Labor, and Pensions Committee--will reduce preventable deaths and hospitalizations.

While these improvements to our health care system are significant and noteworthy, I am disappointed that the bill no longer includes a public insurance option to compete with private plans, nor does it include a provision I have proposed to repeal the antitrust exemption for health and medical malpractice insurers. Though there are differing views on the best ways to inject competition into the health insurance market, we can all agree that health and medical malpractice insurers should not be allowed to engage in blatantly anticompetitive practices, such as colluding to set prices and allocating markets. My legislation would ensure that basic rules of fair competition apply to insurers. I believe that repealing this antitrust exemption, combined with the public option, would go far in providing fair competition and choice in the health insurance marketplace.

With all the progress the Senate's health care bill makes in the area of women's health--such as prohibiting insurance companies from discriminating against women through higher premiums and by allowing women free access to vital preventative services--it is unfortunate the bill also threatens to chip away at women's reproductive choices. Before a restrictive provision was added in the managers' amendment, the bill would have maintained current law by restricting Federal funds for abortions. The original Senate bill would have required insurance companies to segregate public and private funds to ensure no public funds would go to abortion services. Now, instead, the Senate bill would require women who purchase insurance on the exchanges to make two payments if they wish to have a wide range of choices. States could also opt out of allowing abortion to be covered at all on their exchanges, leaving women with fewer choices than they have now on the individual insurance market. While this language is far less restrictive than the language in the House-passed legislation, there is legitimate concern that despite the interest of women to have this choice available in the marketplace, this language would prompt private insurers to stop offering such options at all. I hope a better solution comes in conference.

After one of the cliffhanger votes over the course of this long Senate debate, I spoke privately with Vicki Reggie Kennedy, the courageous and insightful widow of our beloved friend, Senator Edward Kennedy. This is a bittersweet time for her and for all who know how fully he was committed to winning this battle to lighten the load for the ordinary Americans who are struggling so mightily today. Health reform was the first of the many causes of his life and of his work in this body.

We talked about how he would have relished this moment, and we talked about how he would have pressed his shoulder to the tiller to steer the Senate toward the right outcome for the American people. Though Senator Kennedy strongly supported including a public option, as I have, along with other reforms such as ending health insurers' antitrust exemption, Vicki Kennedy knows, as I do, that he would be fighting to pass this bill. This is the Senate's opportunity to advance real reform. This is a bill that reflects the core principles the President outlined in beginning this debate early this year.

This is reform based on the existing system of employer-based insurance, offered by private insurers with health services delivered largely within the private sector. But any objective reading of this bill makes crystal clear that this is real reform. This is a bill that will improve the lives of every American. This is a bill that is a credit to this good and great Nation and its people.

At its best, the Senate through our history has been able to act as the conscience of the Nation. Those moments were forged amid fervent debate and with the purpose of advancing a pressing national interest. This is such a time, and my hope and belief is that the Senate did rise to the occasion.

Mr. President--I voted to support of the Patient Protection and Affordable Care Act of 2009, which will reform our Nation's health care system.

This is our chance to fix a broken system. We tried in 1993 and 1994 and failed. Over 15 years have passed since our last effort. This may be our last, best opportunity before we are forced to wait another 15 years for real reform. And our country cannot afford to wait another 15 years. Our system is simply unsustainable.

Now this bill is not perfect, and without question there are items I would like to change. I believe it is a work in progress. However, it accomplishes several important objectives.

The bill is incremental. There will be time to make needed adjustments before it is fully effective.

It expands insurance coverage and provides new consumer protections from insurance company abuses.

It does all this in a fiscally responsible way, reducing the deficit and prolonging the solvency of the Medicare trust fund.

Throughout this process, I have argued that health reform should be incremental. I believe that in many ways, this bill is incremental.

It leaves the best of our health care system in place. The majority of Americans with coverage continually say they are happy with their insurance. Under this legislation, they can keep what they like.

The bill also will be phased in over the next several years. People in need of coverage will receive immediate help in many forms.

Beginning in 2010, next year, the Federal Government will spend $5 billion to establish a high-risk pool, which will provide subsidized coverage for those who have been denied private insurance on account of a preexisting condition.

Young adults will be able to remain on their parents' health insurance until age 26. Many young adults currently lose their coverage as soon as they graduate from college; this will allow them to maintain their coverage while they find a job.

Seniors enrolled in the Medicare prescription drug benefit will receive an additional $500 in drug coverage before they encounter the so-called doughnut hole coverage gap. This is the coverage gap that occurs after seniors spend $2,830 on prescription drug costs. They are then required to pay the full amount out of pocket, until their costs total $4,550. This additional $500 of coverage means that seniors will encounter a small gap in their drug coverage and pay less out of pocket.

There will be new limits on the amount of premium dollars that can be spent on non-health care expenses by all health insurance companies. This is very important--I have long worried that insurance companies spend too much on administrative expenses, like medical underwriting, claims processing, overhead, and profits and salary, and not enough on actual medical care. Starting next year, plans sold in the individual and small group markets must devote at least 80 percent of premium dollars to health care expenses; and plans sold to large groups must spend at least 85 percent of the premium funds they collect on health care services. This provision will give people the assurance that most of their premium dollars go to pay for care.

Also next year, small business can receive tax credits to help cover the cost of covering their employees. These credits will be available on a sliding scale to employers with 25 or fewer employees, with average annual wages of $50,000 or under.

Expansion of community health centers. Beginning in 2011, the Federal program that supports community health centers will begin to receive significant additional funding, totaling $10 billion through 2015.

This expansion of community care helps guarantee that we are providing not just coverage for medical care but also access. A health insurance card does no good if no physician will accept it. These clinics provide care for all and in many places will be the backbone of a reformed health care system.

Finally, in 2014, the full scope of the reform effort will come in place. People will be able to compare their coverage options in newly created exchanges, and in many cases they will receive tax credits to help them purchase coverage.

This allows plenty of time to see how reforms are working and, if necessary, for Congress, the administration, and States to make adjustments to ensure that health reform is effective.

The bill contains several critical insurance industry reforms that will help cover 31 million additional Americans. I am convinced that our country's for-profit health insurance industry operates with profits, not people, in mind. And this legislation will contain a number of new standards that this industry will need to meet.

They will not be allowed to discriminate based on gender.

They will not be able to take away coverage once a person gets sick.

They will not be able to charge more, or deny coverage entirely, based on an individual's health history or preexisting conditions.

Insurance will be sold in regulated markets called exchanges, where consumers can easily compare their different insurance options. Web sites allow Americans to easily compare prices when shopping for airline tickets, and this will extend the idea to health insurance.

These exchanges will work on behalf of consumers to negotiate lower prices and to ensure that participating plans meet high standards. Consumers will receive clear information about what is covered and how much it will cost. They will have several different levels of coverage from which to choose.

Every exchange will also offer two national plans, overseen by the Federal Office of Personnel Management. This office ensures that Federal workers and Members of Congress have good health plan choices. One of the included plans will be offered by a nonprofit company. For consumers in highly concentrated markets with only a few choices, these national plans will provide a new option for quality coverage.

Most importantly, these exchanges will consider the previous behavior of insurance plans. If a company raises rates unfairly over the next several years, exchanges will consider this and decide whether they should be allowed to sell in these new markets.

This is a strong incentive for plans to treat consumers fairly.

All of this is accomplished in a fiscally responsible manner. The bill saves money, and it saves Medicare.

It is clear that we cannot afford to continue on our current path.

It expands coverage to an additional 31 million Americans while reducing the Federal budget deficit by $132 billion by 2019. Deficit reduction increases in the second 10-year period that the bill will be in effect.

Now, this is a major point of contention. I continue to hear the other side say that this bill will cost $2.5 trillion over 10 years. Even the Republicans' own analysis shows that the bill will reduce the budget deficit. The Budget Committee's minority staff released an analysis that examines the bill's net cost and savings over the next several decades.

The Republican staff projects that the bill will reduce the deficit by $176 billion from 2014 to 2023.

This number grows to $1.032 trillion from 2020 to 2029.

The total net deficit reduction, according to Republicans, is $1.165 trillion from 2010 to 2029.

Let me say it again. These are partisan estimates, produced by Republican staff, and they show significant, meaningful deficit reduction.

The bill also takes a first step at prolonging the solvency of the Medicare Program. Without action, Medicare will be insolvent in 2017. That is 9 short years from now.

This bill extends Medicare's solvency by approximately 4 to 5 years. Make no mistake, more must be done. The Chief Actuary at the Centers for Medicare and Medicaid estimates that it extends solvency to 2026. And I believe this bill lays the groundwork to help make Medicare more sustainable.

It contains a Medicare Commission, which will examine the program and make recommendations to Congress on an expedited basis.

It creates accountable care organizations, in which physicians work together to provide more efficient care for patients, while sharing in some of the savings they generate for the Medicare Program.

Controlling entitlement spending must be a priority, and I believe this is an important step in the right direction.

Throughout the health reform process, I have emphasized the importance of a health reform bill that meets the needs of large and complex States such as California.

My State, without question, has one of the largest and most complex health care systems. As a result, we face some of the most complex challenges.

Over 6.6 million Californians are uninsured. The State is experiencing an unprecedented budget crisis. And even after health reform, the State will still have as many as 2 million undocumented, which will continue to strain public hospitals, emergency rooms, clinics and other providers.

California's public hospitals play a key role in meeting these needs and care for the poorest of the poor. These hospitals rely on payments called Medicaid disproportionate share hospital, DSH, funding to cover their costs, both for the uninsured that they cover and the very low reimbursement rates their receive from the Medicaid Program. DSH funding accounts for, on average, 40 percent of public hospitals' total funding.

I am pleased that the managers' amendment has slightly reduced the annual cut to Medicaid DSH funding that California and other States that use their full allotments will receive.

Under the original bill, California would have received a 50 percent cut in Medicaid DSH once the rate of the uninsured in the state dropped by 45 percent under this version, the state's allotment will only be cut by 35 percent. This reduces a $550 million cut to $385 million, for a savings of approximately $165 million per year to California.

States are now guaranteed to keep at least 50 percent of their current Medicaid DSH allotments, which will provide long-term stability to this critical program.

I am grateful to Senator Reid for making these adjustments, and I will continue to work with my colleagues in the House to keep as much of this critical funding intact as possible as the process moves forward.

The cost to California from the expansion of Medicaid remains a serious concern.

The bill will cover the full cost through 2016 generated by opening the program to all adults who earn less than $14,400 per year, which is 133 percent of the Federal Poverty Level, FPL. However, California will need to maintain this expansion and will also have to find a sufficient number of doctors willing to take patients newly eligible for Medicaid.

This will cost money. Health reform should not bankrupt large States like California. Ensuring that health reform works for my State will be a top priority as this legislation moves to conference.

I am also concerned that the structure of the annual tax on the health insurance sector may have unintended consequences that will have a disproportionate impact on California. This tax will generate roughly $60 billion over the next 10 years.

The impact of this provision would be disproportionate on States such as California, which have a high proportion of fully insured coverage. For example, 77 percent of the commercially enrolled population in California is enrolled in fully insured health plans. This includes public employee plans such as CalPERS and the city and county of San Francisco.

The net result is that California would pay upwards of one-third more than the average State on a per capita basis. Many integrated nonprofit health plans, some of which have been cited as models of efficiency, would face additional expenses and consumers would be impacted through higher premiums and limited choices.

Now, an exemption is provided for nonprofit insurers in the managers' amendment--for example, nonprofits with an overall medical loss ratio of 90 percent or better or nonprofits in a State which regulates premium increases could be exempt from the tax.

But this would have a limited impact in California and our two largest nonprofit insurers--Kaiser Permanente and Blue Cross/Blue Shield may not qualify for the exemption. Because California lacks an entity to regulate premium increases, the only way nonprofit insurers in our State will likely qualify for an exemption is by meeting the medical loss ratio requirements, set at 90 percent overall in the bill. This is a high hurdle to meet, and I worry these additional costs could appear in the premiums paid by Californians.

The most important component of successful health reform remains controlling health insurance premium increases. I remain concerned that companies will attempt to take advantage of the period of time between the passage of legislation, and 2014, when exchanges are up and running with new consumer protections. We have seen this with credit card companies since credit card reform legislation passed, and I fear health insurance will be no different.

I proposed an amendment to create a Medical Insurance Rate Authority and to ensure that all insurance companies are subject to some type of rate review.

The amendment asks the National Association of Insurance Commissioners to produce a report, detailing the rate review laws and capabilities in all 50 States. The Secretary of HHS will then use these findings to determine which States are capable of doing sufficient rate reviews to protect consumers.

In States where insurance commissioners have authority to review rates, they will continue to do so. In States without sufficient authority or resources, the Secretary of HHS will review rates and take any appropriate action to deny unfair requests. This could mean blocking unjustified rate increases, or requiring rebates, if an unfair increase is already in effect. This will provide all American consumers with another layer of protection from an unfair premium increase.

The amendment would also require the Secretary of Health and Human Services to establish a Medical Insurance Rate Authority as part of the process in the bill that enables her to monitor premium costs.

The Rate Authority would advise the Secretary on insurance rate review and would be composed of seven officials who represent the full scope of the health care system including at least two consumers, at least one medical professional, and one representative of the medical insurance industry. The remaining members would be experts in health economics, actuarial science, or other sectors of the health care system.

Unfortunately, this amendment was not included, at the insistence of one member of our caucus. I look forward to working with conferees to find some way to ensure that more Americans are protected from unfair premium increases.

With all the debate over offsets, CBO projections, premiums, and matching funds, it is easy to forget that at the end of the day, we are talking about people. The bill we are debating, I believe, will save lives.

A lack of health insurance is more than an inconvenience; it can be deadly. Americans age 64 and under who lack health insurance have a 40- percent higher risk of death than those who have coverage. This is Dr. David Himmelstein from a Harvard Medical School Study of September 2009.

These are real people, who die earlier than they need to because of problems getting coverage and problems with our health care system. Expanding health coverage is a moral issue, one that, I believe, reflects the character of our Nation. In the richest country in the world, no one should die because they cannot afford health coverage.

For all of this bill's imperfections, I am convinced that it will mean the difference between life and death for some people. And it is not every day that we can say that about a piece of legislation.

We could not pass up this opportunity.

I have joined my colleagues in supporting this bill.

Madam Speaker, I raise a point of order against H. Res. 976 because the resolution violates section 426(a) of the Congressional Budget Act. The resolution contains a waiver of all points of order against consideration of the legislation, which includes a waiver of section 425 of the Congressional Budget Act, which causes a violation of section 426(1).

Madam Speaker, approximately 68 years ago, in January of 1941, Sam Rayburn was elected Speaker of the House of Representatives. Just prior to his swearing in, he rose on the House floor and said the following:

``You have elevated me to a position, I must confess, that has been one of the ambitions of my lifetime. The House of Representatives has been my life and my love for this more than a quarter of a century. I love its traditions; I love its precedents; I love its dignity; I glory in the power of the House of Representatives. It is my highest hope and my unswerving aim to preserve, protect, and defend the rights, prerogatives, and the power of the House of Representatives.''

What a beautiful statement. You can't help but hear and feel the words of love that Speaker Rayburn felt for this House. As Speaker, he considered himself a custodian of its traditions, its precedents and, as he put it, its dignity.

You might ask why I tell this story, why I raise this point. It is because we are about to consider a bill that endorses and condones a practice that has placed a dark and ominous cloud over this institution. This practice, for lack of a better term, can be called circular fund-raising. It involves the awarding of earmarks, which are essentially no-bid contracts, in close proximity to the receipt of campaign contributions from the earmark recipients.

This legislation contains more than 500 earmarks where a private, for-profit company is the intended recipient. Let me repeat that. This legislation we are about to consider contains more than 500 earmarks, or no-bid contracts, directed to private companies. In many cases, the Members of the Congress securing these no-bid contracts have either received, or will soon receive after this legislation is enacted into law, large campaign contributions from the executives of these companies and/or the lobbyists that represent them.

By now my colleagues are well aware of the PMA scandal which was largely centered on the practice of circular fund-raising. Since news broke in February 2008 of the FBI's raid of the PMA offices, press reports and editorials from coast to coast have raised questions about the action of that firm and the integrity of this body, sowing public distrust and tarnishing the dignity of the House. Just listen to what is being said off the Hill and beyond the beltway.

ABC's news site, The Blotter, noted that PMA's ``operations--millions out to lawmakers, hundreds of millions back in earmarks for clients-- have made it, for many observers, the poster child for tacit `pay-to- play' politics in Washington.''

An editorial in The New York Times entitled, ``Political Animal 101'' referred to ``the relationship between campaign donors and the customized appropriations they are fed by grateful lawmakers'' as ``the ultimate in symbiotic survival'' and ``cynical influence trading.''

An article in The Kansas City Star noted that ``the earmark game gets a bit less baffling'' when taxpayers consider ``the campaign donors that grease political palms.''

The Columbus Dispatch summed it up when they noted, ``Congress has an abysmal public approval rating of 26 percent as of early November, and the smell of quid pro quo certainly doesn't help.''

The embarrassing coverage isn't just limited to domestic press. The Irish Times noted that ``U.S. Congressmen tread a fine line between legitimate political fund-raising and influence-peddling, between friendship with lobbyists and outright corruption.'' They go on, ``Now a leaked confidential report, prepared by the committee (on Ethics) in July and detailed in yesterday's Washington Post, has provided a rare glimpse into the cesspool of Capitol Hill politics.''

Madam Speaker, I have here that article referred to from The Washington Post dated October 30 of this year. It notes that seven Members who sit on the Appropriations Committee, the Subcommittee on Defense, are ``under scrutiny by ethics investigators.'' The article notes that ``Together, the seven legislators have personally steered more than $200 million in earmarks to clients of the PMA Group in the past 2 years, and received more than $6.2 million in campaign contributions from PMA and its clients in the past decade.''

According to The Wall Street Journal, Members who sit on the Defense Subcommittee have this year alone ``received a total of $141,000 in campaign contributions from companies that received earmarks from the lawmakers.''

So here we are today, Madam Speaker, with a backdrop of investigations into the practice of circular fund-raising by the Justice Department and our own Ethics Committee, yet we are poised to pass a Defense appropriations bill that contains more than 500 no-bid contracts for private companies.

In mid-January of 2010, we will see a quarterly report from the Office of Congressional Ethics that will shed light into their investigations. Thereafter, it is likely that our own Ethics Committee will have to provide additional notice of their actions related to the PMA scandal.

If the future is anything like the past, additional scandals will spring from the earmarks that we approve

today. We are surely, as the poet said, ``traipsing down a flower- strewn path unpricked by thorns of reason.''

I should note that circular fund-raising is not a partisan issue; both parties engage in it. The cloud that hangs over this body rains on Republicans and Democrats alike. But it is fair to ask, what about the dignity of this body? Are we appropriately concerned that the words ``pay-to-play,'' ``quid pro quo,'' ``swamp'' and ``cesspool'' are increasingly routine in articles describing the appropriations process? Should we have no standard higher than whether the abuse of the process rises to the level of an indictable offense?

One thing is clear: The practice of circular fund-raising will someday end. The question is, who will end it? Will it take us, in our own initiative, to clean our own House, or will we wait for the Justice Department to launch more investigations and take further action?

My own hope is that those who find themselves in leadership positions today will summon the dormant custodial spirit of those who have protected and defended this wonderful institution long before we arrived in this Chamber. We owe it to them to correct the process that led to this flawed piece of legislation before us.

I reserve the balance of my time.

Madam Speaker, may I inquire as to the time remaining?

I am accused of using a procedural measure to bring up earmarks again. Let me tell you why I'm doing that. I'm doing that because this year, for the first time in the history of this institution, every appropriations bill that came to the floor-- including this one, including the Defense appropriations bill--came under a structured or closed rule with only certain amendments being offered. That's the first time in the history of this institution where every appropriations bill has come to the floor in that manner.

And so individuals like myself and others were only allowed to offer the amendments that the other side wanted us to offer, the ones that they said we could offer rather than the ones that we ourselves would choose. I was fortunate in that I got 10 of the 550-some amendments I offered on this bill. I offered that many because that's how many no- bid contracts for private companies are contained in the bill, and I thought that they deserved some scrutiny.

I wish that the Appropriations Committee was vetting these earmarks; given this, it's clear that they're not. This is one of hundreds of articles out there. There is a cloud hanging over this institution because of prior Defense bills, and this is going to end up the same way. We are guaranteeing that there will be scandal that springs from earmarks approved in this bill because they haven't been appropriately vetted, and they haven't been because we weren't allowed an open rule for people to bring to the floor amendments that they wanted to offer.

I mentioned that I was fortunate in that I got 10 of them. Some of my colleagues offered multiple amendments on multiple appropriations bills throughout the year and weren't given the opportunity to offer any of them, not one. Here are Members across the country wanting to represent their constituents, and through the entire appropriations process, 12 bills this year, weren't given the opportunity to offer one amendment because we have the equivalent of martial law on appropriations bills.

And why? Because we were told we had to get it done so we wouldn't do any omnibus bills at the end of the year. Well, here we are, we just approved a massive omnibus bill last week, and we're here today because the Defense bill was held just so that we could tag on additional items that people who wouldn't want to vote for them anyway would have to because it's a Defense bill. That's just no way to conduct business. This institution deserves better than this. It deserves better than to have a bill that has more than 500 no-bid contracts for private companies of which articles have been written and will be written, making a cloud hang over this body.

As I mentioned, this isn't a partisan issue. This isn't where one party is in the right and one party is in the wrong. We are both doing this, and we shouldn't. And it will come back to haunt us as surely as other practices have in the past.

Madam Speaker, I yield back the balance of my time.

I thank the gentlewoman for yielding.

I had hoped that the gentleman would rise and explain what he just explained.

Now, I will gladly yield to him to explain why this would only apply to earmarks by House Members alone and why the competition requirements don't apply to earmarks that are jointly requested by a House and Senate Member. If we're hanging our hat on language that requires that these earmarks be subject to competition, then surely we would extend it to anything that had our name on it, but we're not.

My understanding is that the language only applies to those earmarks that are requested solely by a House Member, and that if you have a Senate Member on your earmark request, then it is not subject to competition. The language just explained does not apply to it. So you can't have it both ways.

Now, I will argue that it doesn't matter anyway, because right now if you talk to the Department of Defense, and I have, we've held meetings in my office with the procurement officials, and we've asked them, How does this work when these earmarks come over? Are they subject to competition? They said, Yes, we follow the rules. Yet when you ask them to do a cursory examination or a full-fledged examination of those earmarks that were requested in prior years, you will find an uncanny alignment, as you might expect, between the intended recipient and those who actually got the earmarks in the end.

So you can say until you're blue in the face we're going to subject these to full and open competition. The Department of Defense already says that. And these articles that I already talked about, these scandals that are currently underway are under a policy where the Department of Defense already says we subject these to full and open competition. But let me tell you, if an earmark comes over from a Member of Congress, particularly from those on the Appropriations Committee--and I should explain that the majority of these earmarks, a disproportionate number, are from the powerful Members on the Appropriations Committee--believe me, those procurement officials at the Department of Defense take that into account. They know who butters their bread, and they know that they'd better award this contract to the intended recipient or they might not get funded the next year. If that's not the case, why have we seen so much an uncanny alignment between the intended recipient and those who actually got the earmark in the first place?

So, first, again let me say if we're hanging our hat on the language that says these are subject to competition, then why wouldn't we apply it to every earmark that is contained in this bill? It doesn't apply to Senate earmarks, nor does it apply to earmarks requested by both Senate and House Members. So are we saying, well, we're going to subject some to competition and that means something, but these others, yes, it's okay if there are no-bid contracts? That simply doesn't work.

I thank the gentlewoman for her indulgence here.

This is important, and I would ask the gentleman and would yield to him to respond, is it your understanding, then, that this language, this new competition language, applies to Senate earmarks as well as earmarks requested by both House and Senate Members?

I thank the gentleman. Let me simply say if that is the case, that is in conflict with the agreement that we understand to be in effect.

The agreement we understand to be in effect and what I was told is that only those earmarks that are requested solely by a House Member has the language that applies to competition. If it is an earmark requested by both a House and a Senate Member, then it does not apply this year, and supposedly it will next year, although obviously there are no guarantees. We can't bind a future session. And that if it is a Senate earmark, they didn't agree to this at all. That's what we understand. If there is some difference there, then please let's have the chairman of the Appropriations Committee explain it.

But, again, the question here is if that language is so important, then why wouldn't we apply it across the board?

And doesn't it strike everybody a little bit funny that you have an earmark that, when a Member requests it from the Appropriations Committee, they say this earmark of this amount, $500,000, $2 million, $2.5 million, whatever, is to go to this company at this address? It's that specific. It goes to that company at that address.

Now, the Appropriations Committee will say we're just providing a look-see, and so the Department of Defense can say, well, we didn't know that that company existed but now we do, and we're doing nothing more than simply giving them a look-see and giving them a chance to see which companies those are. I think that doesn't quite pass the laugh test.

Yes, I will.

I thank the gentleman for explaining my motives.

But in truth what I would like to see is no more earmarks in the defense bill because when you have an earmark, you don't have full and open competition. What I'm talking about is I would not like to see no- bid contracts for private companies in the defense bill. When you have that, I don't know how in the world you can say we have full and open competition.

Like I say, I don't believe that that language means much at all, but to the extent that you believe it does mean something, then at least you should apply it across the board, not just to earmarks sought by Members of the House solely but those earmarks that are requested by Senate Members as well. How can we say with a straight face that, hey, we're doing things right because we're applying that competition language to us, but all you have to do is to get a Senate Member to request it along with you and then you don't have to subject it to full and open competition. It simply doesn't make sense, Madam Speaker.

I thank the gentlewoman for her indulgence and I appreciate this discussion.

Announcement by the Speaker Pro Tempore

Mr. President, I wish to begin by recognizing the work on this legislation of Leader Reid, Chairman Baucus, Chairman Harkin, and Chairman Dodd.

I believe, when the history of this bill is written, it will be recognized what a remarkable job of leadership Senator Reid has provided, bringing together a disparate caucus around extraordinarily complex issues to accomplish something that will be seen in the future as a leap forward for America in reforming the health care system in this country.

Chairman Baucus--no one has made a deeper, more committed, personal sacrifice than Senator Baucus in advancing this legislation. His commitment to getting this bill done and getting it done right will stand the test of history.

Chairman Harkin, who succeeded Chairman Kennedy, made major contributions on the wellness provisions.

Chairman Dodd, who filled in for Chairman Kennedy and continued in the role of handling this legislation, even while being chairman of the Banking Committee, provided an example of legislative leadership that is unmatched.

The four of them have done a superb job in putting together the pieces of the bill that I believe will lead the way to a dramatically improved health care system in our country.

If we reflect, objectively, on the package before us, it is an entirely reasonable and responsible approach. There is no government takeover of health care, no rationing, no cuts to guaranteed Medicare benefits, no benefits for illegal immigrants, and the bill sets a goal of no taxpayer funding for abortion beyond the Hyde amendment provisions in current law.

In fact, this bill does much of what Republicans said they want in a health care plan. It is fully paid for, and it reduces deficits in both the short and the long term. It expands coverage and provides assistance to help families and small businesses afford health insurance. It sets new rules to stop insurance company abuses. It reforms the delivery system to control costs and improve quality. It allows for the sale of insurance across State lines. It supports medical malpractice reforms.

Those are facts. Every one of those elements is in this bill. This is an approach that Senators on both sides of the aisle, who want solutions rather than slogans, should embrace.

The need to act is clear. The status quo is simply unsustainable. Health care costs are crushing families, businesses, and even the government. The premiums for individuals and families are rising three times as fast as wages. You can see where we are headed. It is as clear as it can be.

Without action, families will see average health care premiums rise to $22,000 a family by 2019--$22,000, on average, for family health care premiums in 2019, unless we act.

It does not stop there. Premiums, as I have indicated, are skyrocketing, and national health care costs are skyrocketing right along with them. Without action, total health care spending will equal 38 percent of the gross domestic product of the country by 2050. Thirty-eight percent of the gross domestic product for health care? That would be one in every two and half dollars in this economy. Already, we are consuming one in every six in this economy on health care, and that is an unsustainable course. These costs are driving our long-term fiscal imbalances, threatening our future economic prosperity.

Without action, Federal spending on Medicare and Medicaid will reach 12.7 percent of GDP by 2050. This chart I have in the Chamber makes it very clear. In 1980, the two programs were consuming 2 percent of gross domestic product, but on the current trend line, by 2050, these two-- Medicare and Medicaid--will consume more than 12 percent of our GDP-- one in every eight dollars in our economy.

The growth in health care costs threatens to bankrupt Medicare. Medicare went cash negative last year. Without action, Medicare will be bankrupt in 2017. The trustees have just told us that will happen. That is 2 years earlier than forecast just last year. Again, Medicare went cash negative already. That means more money is going out than is coming in, in the Medicare accounts, and it will be insolvent--broke-- in 8 years. This legislation extends its life by 9 years.

These health care costs are hurting our competitive position in the world. We are spending far more than other countries on health care, leaving less money for research and development, investment, and higher wages for Americans. In fact, as a percentage of our gross domestic product, we spend twice as much as most other advanced countries.

Here it is, as shown on this chart. We are now even higher than 16 percent of our GDP. The latest numbers indicate we have gone to 17 percent of our GDP for health care. That is one in every six dollars. Look at other countries. Japan and the United Kingdom are half as much; Belgium, Germany, Switzerland, France, a little over half as much as we are paying.

But even with the fact that we are spending more, we are actually performing worse on virtually every metric on health care outcomes. We are ranked 19th in preventable deaths, 22nd in infant mortality, 24th in life expectancy; and we still leave 46 million people without insurance.

Continuing the status quo is not an option. America can do better, and this bill proves it. The bill before us is fiscally responsible. The nonpartisan Congressional Budget Office--the official scorekeeper, relied on by both sides of the aisle--tells us the bill reduces the deficit by $130 billion over the first 10 years.

Now, those aren't my numbers, those aren't the numbers of the chairman of the Finance Committee, those aren't the Democratic leader's numbers. Those are the numbers of the nonpartisan Congressional Budget Office. They say this bill will reduce the deficit by $130 billion over the first 10 years.

The savings in the following decade are even more impressive: between $650 billion and $1.3 trillion. The Congressional Budget Office says:

All told, CBO expects that the legislation, if enacted,

would reduce Federal budget deficits over the decade after

2019 relative to those projected under current law--with a

total effect during that decade that is in a broad range

between one-quarter percent and one-half percent of gross

domestic product.

One-quarter and one-half percent of GDP for that second 10 years is $650 billion to $1.3 trillion. Shame on those who get up on the other side and say this is going to increase the deficit. Where is their evidence, other than claims, other than assertions? We are talking about the considered judgment of the Congressional Budget Office that is nonpartisan and is the official scorekeeper for the Congress of the United States.

The bill bends the cost curve for the Federal commitment to health care in the long term. In its December 19 estimate, CBO reports that the proposal would generate a reduction in the Federal budgetary commitment to health care during the decade following the 10-year budget window. So, yes, it bends the cost curve for the Federal expenditure during that period.

This legislation also reforms the insurance market. We have all heard the horror stories. I have loads of letters in my office from constituents telling me about what has happened to them: being dropped because they got sick, even after paying years of premiums; being denied coverage because of preexisting conditions, in many cases preexisting conditions that had nothing to do with the illness for which they now need assistance; and being denied even though they have paid the premiums. This is serious business.

This bill puts a stop to these abuses. It prohibits insurers from denying coverage for preexisting conditions on new policies. It prohibits insurers from rescinding coverage when people become sick after they have paid premiums for years on new plans. It bans insurers from lifetime caps and annual limits on health care benefits, and it prevents insurers from charging more based on health status.

It also expands choice and competition. The bill before us builds on our current market-based system and makes it better. It is not government-run health care. Instead, it embraces choice and competition. It sets up a new health exchange where consumers can shop for the best value. It creates consumer-run, co-op health plans not government-run plans but plans run by the members. It allows for insurance sales across State lines to further increase competition.

The managers' amendment also creates a new national plan. The Office of Personnel Management, the same agency that currently oversees health plans for all Federal employees, including Members of Congress, would select private health insurance carriers to offer plans that would be available nationwide. These plans would provide new competition for State-based health plans, particularly in areas where just one or two insurers currently dominate the market. At least one multistate plan would have to be a not-for-profit insurer, such as one of the newly created co-ops. I am particularly excited by this development.

When we look around the world at the countries with the best outcomes and the lowest cost, one feature stands out: these countries rely on primarily not-for-profit insurance. Germany, France, Switzerland, Belgium, Japan, all have adopted this model. They don't have government-run health care, but they do have universal coverage. They do have extremely high-quality health care outcomes and much lower costs than we do. So I believe the not-for-profit national plans and the co-op option may, in the long run, play a key role in transforming our system into a more efficient, higher quality system.

This legislation also expands coverage. According to the Congressional Budget Office, it covers 94 percent of the American people. It creates State-based exchanges for individuals and small businesses. It provides $476 billion in tax credits to help working Americans and small businesses buy coverage. You don't hear that much from the other side about this $467 billion of tax assistance for people to afford better health care coverage. It also reforms the delivery system to focus on quality and not quantity. The bill before us slows cost growth while improving quality. The sad fact is that 30 percent of current health care spending does nothing to improve health care outcomes. We are wasting about $750 billion a year on unnecessary and counterproductive procedures. Again, that is not a congressional estimate; that comes from a Dartmouth nationwide survey that concluded 30 percent of health care expenditure in this country is wasted. This bill reforms the delivery system in a fundamental way. It contains every delivery system reform health care experts believe is needed to provide better care while slowing cost growth.

This proposal also extends the solvency of Medicare. Medicare's actuary says the Senate bill extends the life of Medicare by 9 years. Some on the other side say that because Medicare is heading toward insolvency, we can't have Medicare savings. What? What are they talking about?

Perhaps the oddest thing I have seen in this debate is the contrast with the last year of the Bush administration. The previous administration sent up a proposal to have nearly $500 billion in savings under Medicare, and we didn't hear one peep from the other side, not one. In fact, they all said it was critically important to do. Now all of a sudden it is the death of Medicare.

What is even more bizarre about their argument is that now there is an offset for the savings from Medicare providers. The offset is they are going to get 30 million new customers, 30 million Americans who haven't had insurance who will now have it so their uncompensated care costs will go down, making it more affordable for providers to provide these savings.

Most of these savings have been negotiated with providers. Why have they been willing to agree to savings--hospitals, nursing homes, and home health care? It is because they know they are going to get substantially expanded business--30 million customers with insurance who previously did not.

This is important legislation. These Medicare reforms don't hurt seniors. Some on the other side have said you can't reduce the growth in Medicare costs without taking benefits away from seniors. That is just scare tactics. The Medicare savings provisions lower cost growth without harming beneficiaries.

This legislation also helps my State. I am proud to say it. Some have said the Medicare changes will hurt North Dakota providers. Clearly, they haven't read the bill. Right now, we get paid way below the average for Medicare reimbursement. In fact, we are the second or third lowest State in the country in Medicare reimbursement. North Dakota providers get $5,000 a year per Medicare beneficiary.

In Miami, they get three times as much, more than $16,000 a year to take care of seniors there. Now I would be the first to say it may cost more to provide medicine in Miami than it does in Minot, but it doesn't cost three times as much. The fact is, moving to a system that is based on outcomes rather than procedures will benefit, not hurt, a State such as North Dakota.

In addition, this legislation includes the frontier States provision that Senator Dorgan and I offered as an amendment. Our provision puts a floor under payments to North Dakota providers and in other States like ours that are rural States that have not received fair levels of reimbursement. It will mean an additional $66 million a year in Medicare payments to my State.

Overall, this bill is a win for North Dakota, a win for the Nation. It reduces the deficit, it controls costs, it saves Medicare--or at least extends its life for at least 9 years--it embraces choice for American consumers and competition and expands coverage. It reforms the insurance industry, and it rewards quality and efficiency.

This legislation is an excellent start. I urge my colleagues to allow it to continue because we all know this isn't the last step. Next we go to the conference committee where we will have

a chance to write the final legislation. No doubt this bill will be further improved as it has been at every step of the process.

Again, let me conclude as I began by thanking the leadership who has made this bill a possibility: Senator Reid, who has done a remarkable job of bringing people together; Senator Baucus, who has spent more than a year and a half in as dedicated an effort as I have ever seen by a committee chairman in this body to bring major legislation to conclusion; Senator Dodd, who filled in for Senator Kennedy on a pinch hit basis but worked so hard to produce a result in that committee; and Senator Harkin, the new chairman of the committee, for all of his assistance in getting the job done.

When the history of this legislation is written, those four will be recognized as producing something that was critically important for this country. We should salute them.

I thank the Chair and yield the floor.