Medicare Physician Fairness Act of 2009

I ask unanimous consent that of the 30 minutes that I control, the ranking member of the Ways and Means Committee, the gentleman from Michigan (Mr. Camp), control 15 of those minutes.

I would yield myself 1 minute.

Mr. Speaker, the only fix that's in this bill before us is ``the fix is in.'' This is nothing more than a repayment to the American Medical Association for endorsing the larger health care bill that was on the floor several weeks ago. There is not one dime of pay-for in this bill. It is a wave the magic wand, erase the accumulated deficit of the last 10 years or so in the SGR formula, and let's kick the can on down the road.

The bill is so narrowly construed that we couldn't offer in the motion to recommit a real pay-for because this bill doesn't have a pay- for. This is nothing more than a political payoff to the American Medical Association. Republicans support really fixing the SGR system, but we think it ought to be done all at the same time. So we would hope that we would vote against this sham today.

I reserve the balance of my time.

Parliamentary inquiry.

Under the rules that we operate where we alternate back and forth, is it allowable for myself to make a rebuttal and then recognize the gentleman from Indiana? Or do I have to do one or the other?

I am going to recognize myself for 1 minute to comment on my friend from Maryland's comments. Then hopefully the Chair will let me recognize the gentleman from Indiana (Mr. Pence) for 3 minutes.

Mr. Speaker, first of all, under Republican control, every bill that we brought to the floor, except one bill, was paid for either in that bill or in our budget resolution. There was one exception to that where we did not pay for it. So that is answer number one. Answer number two, this is not paid for. Under a bill that my friends in the majority passed in July, they say we're going to start pay-for, but it doesn't count for the doctors fix, it doesn't count for the alternative minimum tax, and it doesn't count for the estate tax.

But once we do all that without paying for it, then the pay for will kick in. So in that sense, my good friend from Maryland is accurate. But in the sense of this bill, he is totally inaccurate. This bill is not paid for.

Now, Mr. Speaker, if I am allowed to, I yield 3 minutes to my good friend from Indiana (Mr. Pence).

(Mr. PENCE asked and was given permission to revise and extend his remarks.)

I yield 1 minute to the gentleman from Kentucky (Mr. Whitfield), a member of the Health Subcommittee.

I yield myself 1 minute.

I would ask the distinguished chairman of the Health Subcommittee:

Where is the fix? There is no fix in this bill.

They split one formula into two, but there is no reform in it. It is not based on medical expenses. It is not based on anything. There is no automatic reduction. It simply erases the current deficit in the account, has two formulas instead of one, and then 4 or 5 years from now, we will kick the can down the road again.

If there really is a fix, let's have somebody on the majority side explain it. You can't explain it because it is not there.

I yield 1 minute to a member of the Health Subcommittee, the gentleman from Georgia (Mr. Gingrey).

Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from Texas (Mr. Gohmert).

Mr. Speaker, I yield myself 1 minute.

Since my friends on the Democrat side won't explain their procedure, their bill, I am going to try and do it, and if I am wrong, I am sure that they will correct me.

Current law, we have one SGR formula. It is based on GDP and inflation. It is not based on any kind of medical index. Whatever that is perceived to be each year, that is the amount of increase we can pay our physicians. All physicians get the same increase.

Under this bill, they say if you are a primary care doctor, you get the formula plus 2 percent. If you are a specialist, you get the formula plus 1 percent, but they don't change the formula. The formula is the same as it is under the current law, and they don't change the enforcement mechanism. The enforcement mechanism is the same as it is under current law; i.e., Congress has to vote to either accept the cuts or to not accept the cuts and provide a temporary fix. As I understand it, that is their fix. Now, if I am wrong in that, I want my friend Mr. Waxman or Mr. Pallone or Mr. Rangel or Mr. Stark to tell me how I am wrong.

Mr. Speaker, I yield 1 minute to the gentleman from Nebraska (Mr. Terry), a member of the Energy and Commerce Committee.

Mr. Speaker, I yield 1 minute to the distinguished minority leader from the great State of Ohio (Mr. Boehner).

Mr. Speaker, could I inquire as to how much time I still control, please.

I want to yield 1 of those 3 minutes to the gentlewoman from Nashville, Tennessee, a member of the Energy and Commerce Committee, Congresswoman Marsha Blackburn.

Mr. Speaker, I'm not used to dealing with a warm and fuzzy Pete Stark. I have to admit that was a very good speech.

Mr. Speaker, I yield 1 minute to my good friend from Michigan from the Energy and Commerce Committee, Mr. Rogers.

Mr. Speaker, I yield myself the balance of the time.

I'd like to put into the Record a statement from the vice chairman of the American Medical Association on March 20, 1997, where they went on record before the Ways and Means Committee subcommittee supporting the current system. And now, I understand and I accept what Subcommittee Chairman Stark said, that mistakes have been made, and I think, in hindsight, both sides can agree that a mistake has been made.

It is my opinion, and I think most of the Republicans would share this opinion, that this is not the solution. When all you do is change which formula gets reimbursed, either primary care or specialist, but you use the same underlying formula, the same lack of enforcement, that's not, in my opinion, a fix. So respectfully, I believe that we should defeat this bill and then work together.

I do sense some bipartisanship on this floor. Let's work together to come up with a real fix. It will not be easy. It's not easy to come up with $350 billion. It's not easy to allocate that. It's not easy to change the formula to something that more accurately reflects the costs of practicing medicine in the modern era. But, we can do it. This is not the solution. I hope we'll vote this down.

As has been pointed out, this bill isn't going anywhere in the Senate. This is an act, in my opinion, of paying off a political debt to the American Medical Association for endorsing the larger health care bill several weeks ago. Please vote ``no.''

Statement of Thomas R. Reardon, M.D., Vice Chair, American Medical

Association

Mr. Chairman, my name is Thomas R. Reardon, M.D. I am a

general practitioner from Boring, Oregon, and a member of the

Board of Trustees for the American Medical Association (AMA).

On behalf of the 300,000 physician and medical student

members of the AMA, I thank you for this opportunity to

testify before the Subcommittee today regarding Medicare

physician payment issues.

A wide range of experts have independently concluded that,

despite Medicare's clear success in improving the health

status of our elderly and disabled citizens, the program

cannot be sustained without fundamental restructuring. The

Hospital Insurance Trust Fund faces bankruptcy in five years

or less, and Medicare's current overall expenditure growth

cannot be sustained. Medicare faces a much more serious long-

term problem as the ``baby boom'' generation ages and the

number of workers paying taxes for every Medicare

beneficiaries will decline from 3.9 currently to only 2.2 in

the year 2030.

The high growth rates for many of the services are due to a

combination of factors, including increased beneficiary

demand for new services, flaws in payment rules which

encourage high volume growth in some categories of service,

insulation of most beneficiaries from cost considerations,

and ineffective approaches to cost control. However, as the

chart below indicates, physician spending growth is well

below the rate for any other major sector of Medicare, and

well below overall Medicare growth. The AMA is pleased that

the President's 1998 budget proposal explicitly recognizes

this fact.

We are also pleased that the Administration's budget

supports the development of innovative provider sponsored

organizations in order to offer greater choice to Medicare

beneficiaries. We believe these types of options hold the

promise of enhancing beneficiary choice while controlling

Medicare's costs. The AMA also supports the President's

investment in preventive health care to improve seniors'

health status by covering colorectal screening, diabetes

management, and annual mammograms without copayments, and by

increasing reimbursement rates for immunizations to ensure

that Medicare beneficiaries are protected from pneumonia,

influenza and hepatitis.

Unfortunately, the Administration's budget primarily adopts

the strategy of cutting physician and other provider payments

in hopes of getting more services for less money. We believe

this approach will ultimately divorce the Medicare system and

its beneficiaries from the mainstream of American medical

care, while postponing the major restructuring needed for

Medicare's long-term survival. In the meantime, the long-term

problems will only grow larger, requiring more draconian and

expensive solutions.

AMA's Proposal For Medicare Transformation

The AMA has a plan which addresses both the short and long-

term problems with Medicare, while preserving the bond of

trust between a patient and physician that makes medicine

unique. The AMA's Transforming Medicare proposal is based on

the idea of a competitive market-driven system as the best

option for the future of the Medicare program because it

offers more choice to senior citizens and the disabled. We

must give the patient both the opportunity and the

responsibility to make wise prospective choices of physician

and health plan, with the reasonable opportunity to change

either if they prove unsatisfactory.

Our plan would modernize traditional Medicare, eliminating

the need for Medigap, while preserving the security and

quality of care beneficiaries now receive. It would create a

new MediChoice option, which would provide a broad menu of

health plan choices for Medicare beneficiaries to choose

from, including medical savings accounts and provider

sponsored organizations. And finally, it would ensure that a

healthy Medicare is available for future generations. The AMA

would welcome the opportunity to discuss our Transforming

Medicare proposal with the Subcommittee in greater detail at

an appropriate forum.

Improving the Physician Payment System

The Administration's 1998 budget proposal targets $5

billion in savings over five years from refinements to the

Medicare physician payment schedule. In particular, the

Administration proposes moving to a single conversion factor

(CF) for the payment schedule, and replacing the current

Medicare Volume Performance Standard (MVPS) update formula

with a Sustainable Growth Rate (SGR) formula.

Under the Administration's budget proposal, the overall

payment update for 1998 would be set at 1.9%, yielding an

overall CF of $36.63 in 1998. With the move to a single CF of

$36.63, surgical service payments would fall by 10.6%

compared to 1997 levels, while primary care payments would

increase by 2.4% and other service payments would increase by

8.2%. The payment reductions for surgical services are

further exacerbated by the implementation of resource-based

practice expense relative value units scheduled for 1998, as

discussed below.

The AMA has consistently sought a return to a single growth

standard and conversion factor for physician services. We

adopted this position well before any indication of which

services would benefit from multiple standards. At our Annual

House of Delegates meeting in 1996, AMA policy was modified

to adopt a compromise that responds to two realties. First,

because moving to a single conversion factor could lead to

large single year cuts for some services and specialties, we

support a transition of as close to three years as possible.

Second, because we also recognize that one of the purposes of

a transition is to allow those who face cuts time to adjust,

and that there has been ``fair notice'' of a shift to a

single conversion factor, our House of Delegates voted that

the ``clock should start running'' on such a transition on

January 1, 1997.

In addition to moving to a single conversion factor, the

AMA supports replacing the MVPS system of updating physician

payments. There is widespread agreement that the current

method of updating physician payments, the MVPS system, is

fundamentally flawed. The Congress, the Administration, and

the Physician Payment Review Commission (PPRC) have all

proposed replacing the current MVPS update formula with a

sustainable growth rate (SGR) formula, which uses real per

capita gross domestic product (GDP) to adjust for volume and

intensity.

The Administration's fiscal year 1998 budget proposes

implementing an SGR formula, with the volume target in the

SGR formula initially set at growth in real per-capita GDP

plus one percentage point. However, the Congressional Budget

Office (CBO) scoring of the proposal apparently failed to

yield the targeted savings of $5 billion in savings from the

Medicare fee schedule, and the volume allowance in the SGR

was reportedly reduced to GDP+0.

In general, the AMA supports implementing the SGR approach

as a needed correction for the MVPS. Fundamentally, the

question for policymakers is determining the level of annual

spending growth for physician services that best balances

patient care

needs and the federal budget. Under the current MVPS

physician update formula, the projected Medicare payment

level for physicians is a steep actual decline, while

hospital and other provider payment rates go up, as the chart

below indicates. Although these non-physician services are

unlikely to see their full projected increases, their

budget savings will be charged against this rising

baseline, while further savings from physicians require

even steeper cuts.

Budget reconciliation for Medicare should reflect the fact

that physician spending is under better control than any

other major Medicare segment, and that the budget baseline

already assumes steep annual payment cuts. Physician practice

costs, as measured by the Medicare Economic Index (MEI),

continue to rise while physician reimbursement under Medicare

is projected to fall. Physicians are only asking for the

opportunity to have Medicare payments keep up with the costs

of providing care to Medicare beneficiaries, and are willing

to accept the challenge of maintaining volume growth at

current low levels.

While we believe that MEI is the appropriate goal for

physician updates, we understand that budgetary constraints

may not presently allow for a full MEI update for physicians.

Physicians are willing to do their part to put Medicare's

fiscal house in order, as we have repeatedly done in the

past. Physicians, who accounted for 32% of combined physician

and hospital Medicare spending from 1987 to 1993, absorbed

43% of Medicare provider cuts over the same time. We would be

willing to accept GDP+2 under an SGR system as a temporary

measure, if there were assurances that this could be

increased to cover MEI once the necessary Medicare savings

were obtained. In contrast, under GDP+O as the Administration

proposes, physician payments would continue to fall well

below MEI, as they are projected to do under the current MVPS

system.

Given a new SGR, with a realistic growth allowance, we

could also support a new ceiling on positive MVPS

adjustments, which would provide direct financial benefits to

the federal budget if actual volume is below target.

Moreover, the federal government receives a very real

additional benefit--the ability to pay for the payment rates

needed to maintain the viability of Medicare fee-for-

service out of reduced service volume. At the same time,

like the PPRC, we believe it essential to maintain the

current 5% maximum payment reduction from the MEI

(increased from 3% by OBRA 93) and to reject

Administration proposals to lower the floor to MEI minus

8.25%.

Resource-Based Practice Expense

As mentioned above, many physicians face additional extreme

payment reductions due to the implementation of the resource-

based practice expense in 1998. The Social Security Act

Amendments of 1994 requires the Health Care Financing

Administration (HCFA) to implement a ``resource-based''

practice expense component of the Medicare fee schedule by

January 1, 1998. That is, the payment for this component--

which represents over 40 percent of the payment for physician

services--is to be based on the actual expenses incurred in

delivering each service. Currently, the practice expense

allowance is derived from a formula based on the prior

reasonable charge payment system.

The AMA supports resource-based practice expenses so long

as they reflect actual practice expenses, but is seeking a

one-year extension of the implementation date. The 1994

legislation said that HCFA should ``recognize the staff,

equipment, and supplies used in the provision of various

medical and surgical services in various settings.'' HCFA

contracted with Abt Associates to conduct a two-part study of

3,000 physician practices expenses. When the survey was

pulled back due to poor response rates, HCFA was left without

adequate data to meet the intent of the law.

HCFA is relying primarily on data derived from clinical

practice expert panels, or CPEPs. Early review of the

recently-released CPEP findings suggest that they contain a

number of errors. HCFA has even rejected certain direct costs

that its expert panels found were part of the cost of surgery

when doctors supply their own staff and supplies in hospital

operating rooms. The AMA and medical specialties are working

to identify and correct those flaws but more time is needed.

Those who want to adhere to the current January 1, 1998,

deadline argue that any problems can be corrected later

through a refinement process similar to the one used when new

work values were implemented in 1992. The AMA believes this

is an inappropriate comparison. HCFA invested nearly three

times as much time and money on the design of new work values

as it has spent to revise practice expense values. Whereas

thousands of doctors were surveyed to come up with the work

values, in the end, there was no broad survey of practice

expenses. Simply put, with work values, the product being

tested was much further along in the development process than

is now the case with practice expense values.

Opponents of an extension also maintain that there is no

point in waiting another year because the demise of the

indirect cost survey shows that it will never be possible to

collect this information independently. We believe that with

another year, HCFA could develop alternative relative values

that bear some relationship to actual practice expenses.

There would be adequate time to validate and correct the CPEP

data. Better indirect cost allocation methodologies could be

developed and tested. Missing data could be collected,

perhaps through an expansion of existing surveys.

The cuts HCFA projected in January are so extreme that they

would nearly eliminate practice cost reimbursement for some

procedures and specialties. Many inpatient surgical

procedures and two specialties could suffer cuts of more than

80% in their practice expense values, and at least 40% in

their total payments. Under HCFA's projections, payments for

many surgical procedures would fall below Medicaid levels.

Thus, there is good reason to fear that if Medicare makes

deep cuts in its payments for complex procedures, doctors

performing these services may find that they can no longer

afford to accept Medicare patients.

In addition, even some of the specialties which seem

relatively unscathed in HCFA's projections could actually

experience significant cuts if other payers pick up the new

Medicare values because the projections do not show the

impact of cuts in procedures usually done on patients under

age 65. To impose such deep payment cuts based on such spotty

research seems certain to undermine physician support for the

Mr. Speaker, I yield myself 3 minutes.

(Mr. STARK asked and was given permission to revise and extend his remarks.)

Mr. Speaker, I would like to place in the Record a letter from the American Medical Association and a list of over 150 supporters of H.R. 3961, among which are the American College of Obstetricians and Gynecologists, the Iowa Medical Society, the Texas Medical Society, all of whom I think place Hippocrates ahead of Sarah Palin in terms of their assessment of what should be done.

I would further begin in addressing my dear friend from Texas in some of his inquiry earlier by quoting from the ranking member of the Health Subcommittee on the Ways and Means Committee back last July when he said he believed Members on both sides of the aisle agree that there is a need for a long-term fix for the Medicare physician payment. All 15 members, Republican members, of the Ways and Means Committee voted basically for the fix we're talking about today.

Let me make no mistake about blame and where we are. It may come as a surprise to our side of the aisle we make mistakes. In 1997 we made a mistake in setting the formula by which we would automatically limit the increase that doctors get paid. Well, we're here today trying to correct that mistake.

You've said so, correctly, that it's the same formula plus 2 percent for primary care, 1 percent for other physicians, some other plans to help encourage primary care doctors to come into practice. Hopefully, we've done it right, and recognizing if we don't correct it, we're talking about hundreds of billions of dollars by postponing. So we have postponed, whether on either side of the aisle, we have postponed correcting a mistake that we should have done earlier.

That's where we are today. No place else. And I hope that we can get the continued support to do that. I hope we don't have to come back and keep addressing it. I see not correcting it increases the amount we will have to pay in the future.

So there is plenty of blame, as the gentleman suggested, to go around. We could have fought harder to correct it earlier. We didn't and that's where we are today.

Literally every major medical society in the country has suggested that we do it this way, and I urge my colleagues to join with me, hopefully with my 15 colleagues on the Ways and Means Committee who haven't changed their mind, and support H.R. 3961 today so we can put this behind us. Then we can go on and have some really spirited debate about whether they do a better job in Texas or California of reforming medical care. That will be more fun.

But today let's fix this. Pass H.R. 3961, go home and have a wonderful Thanksgiving holiday, and come back to work on health care reform.

American Medical Association,

Chicago, IL, November 19, 2009.

Hon. Dave Camp,

Ranking Member, House of Representatives,

Washington, DC.

Dear Representative Camp: Thank you for your letter of

November 18, 2009, regarding the pending Congressional

consideration of H.R. 3961, the Medicare Physician Payment

Reform Act of 2009. We appreciate your agreement that having

physicians face annual cuts due to the flawed SGR is

unacceptable and your support for the intent of the

legislation. As you know, it is the same policy supported by

every Republican on the Ways and Means Committee during the

mark-up of H.R. 3200.

We are disappointed, however, that you and your colleagues

do not support the bill. As you know, the SGR was put into

place by the Balanced Budget Act of 1997, which originated in

your committee. At that time, the AMA wrote numerous letters

to Speaker Gingrich and your committee leadership warning

that limiting growth in physician services to GDP would

inevitably lead to sharp cuts in physician reimbursement and

a crisis in access to care for our nation's seniors.

Previously we had supported legislation that would have

allowed growth at a rate above GDP.

As predicted, the SGR did result in a 4.8% cut to

physicians for the year 2002. Congress declined to intervene

and that cut went into effect. In subsequent years, Congress

did step in to prevent additional cuts from occurring. The

Consolidated Appropriations Resolution of 2003, the Medicare

Modernization Act of 2003, the Deficit Reduction Act of 2005,

the Tax Relief and Health Care Act of 2006, the Medicare,

Medicaid, and SCHIP Extension Act of 2007, and the Medicare

Improvement for Patients and Providers Act of 2008 each

provided temporary relief for seniors and their physicians

from pending cuts.

What these bills did not do, however, was make any progress

toward fixing the problem. Instead, Congress fell into a

comfortable rhythm of kicking the can down the road and

putting off real reform to some unspecified point in the

future. In 2005, physicians faced a cut of 3.3% which was

averted by the MMA. At that time, the Congressional Budget

Office reported that the cost of just a ten-year freeze in

physician rates was $48.6 billion. Just four years later, the

pending cut stood at 21.5% and the cost of a ten year freeze

stood at $285 billion. The AMA believes that this cycle must

come to an end. Anything short of permanent reform will not

be supported by the AMA. Every year that Congress ``pays-

for'' a temporary solution, the cost of permanent reform

climbs higher still. These are obligations to our seniors

which the Medicare program has already made. To pretend that

they will not be incurred is unrealistic. To continue to grow

the size of the problem is irresponsible.

As for the implication that the recent action by the

Administration to remove drugs from the SGR are ``budget

gimmicks to hide the true deficit impact,'' we are reminded

of a letter you signed on May 21, 2004, to the Bush

administration calling the policy of including drugs in the

formula ``our greatest concern'' regarding the magnitude of

the

SGR problem. That letter was also signed by other members of

your committee. On June 16, 2004, Representative Cantor sent

a similar letter with Representative Pryce urging that CMS

``remove prescription drug expenditures from the Sustainable

Growth Rate (SGR) determination.''

The Congressional Record is replete with statements by

members from both sides of the aisle calling for permanent

reform. What is missing, however, is the result. The record

shows temporary patches and a ballooning problem.

The AMA does not support any motion to recommit that would

have a temporary fix. How steep will cuts be after those four

years? How many hundreds of billions of dollars will it then

cost to fix this problem? Medical liability reform remains

among the highest priorities of the AMA and all physicians.

However, when Republicans controlled both chambers of

Congress and the White House, capping damages could not be

accomplished. We fail to see why you believe it is possible

today. With less than seven weeks before Medicare rates are

cut more than 21%, we need solutions that can be achieved

quickly.

This should not be a partisan issue. Both sides of the

aisle have professed a desire to permanently address this

issue. The opportunity to advance permanent reform through

passage of H.R. 3961 cannot be missed. We urge all members to

vote for H.R. 3961.

Sincerely,

J. James Rohack.

H.R. 3961 is supported by a wide range of organizations

representing patients, doctors and other providers,

including: AARP; Air Force Association; Air Force Sergeants

Association; Air Force Women Officers Associated; Alliance

for Retired Americans; AMDA--Dedicated to Long Term Care

Medicine; American Academy of Allergy, Asthma and Immunology;

American Academy of Child and Adolescent Psychiatry; American

Academy of Cosmetic Surgery; American Academy of Dermatology

Association; American Academy of Facial Plastic and

Reconstructive Surgery; American Academy of Family

Physicians; American Academy of Hospice and Palliative

Medicine; American Academy of Neurology Professional

Association.

American Academy of Ophthalmology; American Academy of Pain

Medicine; American Academy of Pediatrics; American Academy of

Sleep Medicine; American Association of Clinical Urologists;

American Association of Hip and Knee Surgeons; American

Association of Neurological Surgeons; American Association of

Neuromuscular and Electrodiagnostic Medicine; American

Association of Orthopaedic Surgeons; American College of

Allergy, Asthma and Immunology; American College of

Cardiology; American College of Chest Physicians; American

College of Emergency Physicians; American College of

Gastroenterology.

American College of Obstetricians and Gynecologists;

American College of Osteopathic Internists; American College

of Osteopathic Surgeons; American College of Physicians;

American College of Radiation Oncology; American College of

Radiology; American College of Rheumatology; American College

of Surgeons; American Gastroenterological Association;

American Geriatrics Society; American Logistics Association;

American Medical Association; American Medical Group

Association; American Osteopathic Academy of Orthopedics;

American Osteopathic Association.

American Psychiatric Association; American Society for

Clinical Pathology; American Society for Gastrointestinal

Endoscopy; American Society for Metabolic and Bariatric

Surgery; American Society for Radiation Oncology; American

Society for Reproductive Medicine; American Society for

Surgery of the Hand; American Society of Addiction Medicine;

American Society of Anesthesiologists; American Society of

Cataract and Refractive Surgery; American Society of Clinical

Oncology; American Society of Hematology; American Society

of Nephrology; American Society of Ophthalmic Plastic and

Reconstructive Surgery; American Society of Plastic

Surgeons.

American Society of Transplant Surgeons; American Thoracic

Society; American Urological Association; AMVETS; Arizona

Medical Association; Arkansas Medical Society; Army Aviation

Association of America; Association of American Medical

Colleges; Association of Military Surgeons of the United

States; Association of the United States Army; Association of

the United States Navy; California Medical Association; Chief

Warrant Officer and Warrant Officer Association of the U.S.

Coast Guard; College of American Pathologists; Colorado

Medical Society.

Commissioned Officers Association of the U.S. Public Health

Service, Inc.; Congress of Neurological Surgeons; Connecticut

State Medical Society; Contact Lens Association of

Ophthalmologists; Emergency Department Practice Management

Association; Enlisted Association of the National Guard of

the United States; Fleet Reserve Association; Florida Medical

Association Inc.; Gold Star Wives of America; Hawaii Medical

Association; Heart Rhythm Society; Idaho Medical Association;

Illinois State Medical Society; Indiana State Medical

Association; Infectious Diseases Society of America.

International Society for Clinical Densitometry;

International Spine Intervention Society; Iowa Medical

Society; Iraq and Afghanistan Veterans of America; Jewish War

Veterans of the United States of America; Joint Council of

Allergy, Asthma and Immunology; Kansas Medical Society;

Kentucky Medical Association; Louisiana State Medical

Society; Maine Medical Association; Marine Corps League;

Marine Corps Reserve Association; Massachusetts Medical

Society; MedChi, The Maryland State Medical Society; Medical

Association of Georgia.

Medical Association of the State of Alabama; Medical Group

Management Association; Medical Society of Delaware; Medical

Society of the District of Columbia; Medical Society of the

State of New York; Medical Society of Virginia; Michigan

State Medical Society; Military Chaplains Association of

the United States of America; Military Officers

Association of America; Military Order of the Purple

Heart; Minnesota Medical Association; Mississippi State

Medical Association; Missouri State Medical Association;

Montana Medical Association; National Association for

Uniformed Services.

National Committee to Preserve Social Security and

Medicare; National Guard Association of the United States;

National Medical Association; National Military Family

Association; National Order of Battlefield Commissions; Naval

Enlisted Reserve Association; Nebraska Medical Association;

Nevada State Medical Association; New Hampshire Medical

Society; New Mexico Medical Society; Non Commissioned

Officers Association; North Carolina Medical Society; North

Dakota Medical Association; Ohio State Medical Association;

Oklahoma State Medical Association.

Oregon Medical Association; Pennsylvania Medical Society;

Renal Physicians Association; Reserve Enlisted Association;

Reserve Officers Association; Rhode Island Medical Society;

Society for Cardiovascular Angiography and Interventions;

Society for Maternal-Fetal Medicine; Society for Vascular

Surgery; Society of Critical Care Medicine; Society of

Gastrointestinal and Endoscopic Surgeons; Society of

Gynecologic Oncologists; Society of Hospital Medicine;

Society of Interventional Radiology; Society of Medical

Consultants to the Armed Forces.

South Carolina Medical Association; South Dakota State

Medical Association; Tennessee Medical Association; Texas

Medical Association; The Endocrine Society; The Retired

Enlisted Association; The Society of Thoracic Surgeons;

United States Army Warrant Officers Association; USCG Chief

Petty Officers Association; Utah Medical Association; Vermont

Medical Society; Veterans of Foreign Wars; Washington State

Medical Association; West Virginia State Medical Association;

Wisconsin Medical Society; Wyoming Medical Society.

Mr. Speaker, I reserve the balance of my time.

Announcement by the Speaker Pro Tempore

Mr. Speaker, at this time I'm delighted to yield 1 minute to the gentleman from Texas (Mr. Doggett).

Mr. Speaker, I am pleased at this time to recognize a distinguished member of the Ways and Means Committee, Mr. Neal of Massachusetts, for 1 minute.

I'd like to recognize Mr. Blumenauer from Oregon for 1 minute, but pending that, I yield myself 30 seconds to respond to my distinguished colleague and ranking member of the Ways and Means Committee that we debated this back in July, and that all of us agreed and voted for the fix that we're talking about today. And I hope that we could continue that. It was done on a bipartisan basis at that time. It was probably the only part of the bill that was bipartisan, but we did all vote for it and voted for exactly what we're talking about today, and I hope we could get those votes again.

I yield to the gentleman from Oregon (Mr. Blumenauer).

Mr. Speaker, could I inquire as to the remaining time on either side?

At this time, Mr. Speaker, I'm delighted to yield 1 minute to the distinguished gentleman from New Jersey (Mr. Pascrell).

I yield the gentleman an additional 15 seconds.

I yield myself 30 seconds, Mr. Speaker, just to remind the distinguished gentleman from Wisconsin that he and 14 of his colleagues voted for this bill in the Ways and Means Committee last July.

I don't mind mixing it up with the health care reform, but it's not. It's the doctor fix.

In just a moment, yes.

The important thing is that if we move this aside, we're correcting the mistake that was made. Let's forget about who made it. It was there.

Now this may not be the end-all correction, but there is no reason that we couldn't come back next year if we find that the formula doesn't work.

I will yield myself an additional 30 seconds.

If we don't do it and we do the 4-year fix that you, Mike, suggested, or the 3-year, and then it doesn't work, we will have $400 billion to correct.

My point is this. If we could remove it for a moment from the discussion on the overall health reform bill--which we can have a spirited discussion on--this is a technical fix which all of your members supported on a bipartisan basis.

I yield to the gentleman from Wisconsin.

Well, as I say, the gentleman supported it a few months ago.

At this point, Mr. Speaker, I'd like to yield 1 minute to the gentlelady from Nevada (Ms. Berkley).

I yield myself such time as I may consume, Mr. Speaker, to remind my distinguished friend from Louisiana that the American College of Cardiology, the Louisiana Medical Association, and most every medical association in the United States has endorsed the legislation.

I reserve the balance of my time.

Parliamentary Inquiry

Mr. Speaker, at this time I am pleased to yield 1\1/2\ minutes to the distinguished gentleman from North Carolina (Mr. Etheridge).

(Mr. ETHERIDGE asked and was given permission to revise and extend his remarks.)

Mr. Speaker, I yield to the gentlewoman from Texas (Ms. Jackson-Lee) for a unanimous consent request.

(Ms. JACKSON-LEE of Texas asked and was given permission to revise and extend her remarks.)

Mr. Speaker, I yield myself the balance of the time.

I again encourage my friends on the other side of the aisle to support this fix for the physician reimbursement. It was correct originally in our major health reform bill. The reason it was separated, I would have to admit, was purely political. We had to abide by the President's request that we did not exceed certain costs, and we separated it for that.

For those of you who suggest that the Senate may do nothing with this, I'm afraid we have to leave that to the American Medical Association and America's physicians. They will have to pressure the Senate to add this at some point in their deliberations. I think it's beyond us to do that, and my suspicion is that with the more than 150 medical societies around the country, they will be able to importune our friends on the other side of the Capitol.

Mr. Speaker, I believe that we will see a format of this bill facing us from the other side. I hope we do. We are talking about postponing any length of time increases, whether it's 4 years and we get $400 billion, whether it's a couple of years and we get $200 billion, there was a mistake made. The distinguished gentleman whom the current ranking member and I know so well is no longer with us. He is probably chuckling up his sleeve at the angst he has caused us.

But we recognize the mistake. We did try to fix it. We did try to fix it on a bipartisan basis. I know there are other issues that are tangential to this. I hope we can put these aside today. Take care of the physician fix. Hopefully we've got the formula right. As I said earlier to the distinguished gentleman from Wisconsin, we might not have it perfect, but we have some time in the next year or 2 to make those adjustments. I commit to you that we certainly will, and I hope that you would work with us to help correct it if that comes in the future so we can set this aside. It's a separate debate.

We are going to have a long and strenuous debate on health care reform as we go down toward the end of the year and into next year. And I look forward to that. But I would like to see this set aside so that we can see that the physician payment fix, which we all know has been facing us for years, is ended today and that we pass this bill.

I thank my friends on the minority side for their kindness in this debate and, Mr. Speaker, I urge passage of the bill.

I yield back the balance of my time.

I thank the gentleman for yielding only to suggest that being nice doesn't seem to get you much around here.

This motion makes a mockery of the debate. My friends on the other side simply propose the same old same old. They can't even tell us or the American people how this will affect doctors or military families or others. It is legislating in the dark.

The distinguished minority whip voted in committee enthusiastically for the bill that is before us, now seems to have forgotten and changed his mind. It is a continuation of the Republican history of mismanagement of Medicare and dishonest budget gimmicks, and I urge its opposition.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, today, the Senate will finally consider the nomination of Roberto A. Lange to the District of South Dakota. It has been 3 weeks since Mr. Lange's nomination was unanimously reported by the Judiciary Committee to the Senate. It should not take 3 weeks to confirm a consensus nominee. I will be interested to hear from Senate Republicans who have stalled this confirmation for the last 3 weeks why they did so.

There are 10 other judicial nominations reported favorably by the Judiciary Committee to the Senate that remain pending without consent from Senate Republicans to proceed to their consideration. These are 10 other judicial nominations on the Senate Executive Calendar awaiting action and being stalled by Republican holds. All 10 were reported favorably by the Senate Judiciary Committee. Two were reported in June and have been waiting for more than 4 months for Senate consideration. These are things that we have always done by voice vote when there is no controversy.

It is not only a dark mark on the Senate for holding us up from doing our work, but it means that the nominees have their lives on hold. They have been given this nomination, and everything has to come to a stop. They know they are going to be confirmed. They know that whenever the Republicans allow a vote, it will be virtually unanimous. It makes the Senate look foolish, and I wish my colleagues would allow these people to move quickly.

The American Bar Association's Standing Committee on the Federal Judiciary reported that its peer review of the President's nomination of Mr. Lange resulted in the highest rating possible, a unanimous rating of well qualified. His nomination has the support of both home State Senators, Senator Johnson, a Democrat, and Senator Thune, a Republican, and was reported out of the Judiciary Committee by unanimous consent on October 1. I expect the vote on the President's nomination of Mr. Lange to be overwhelmingly in favor, as was the 99-0 vote for the only other district court confirmation so far this year, that of Judge Viken. I will be listening intently to hear why then Senate Republicans--despite the support of Senator Thune, the head of the Republican Policy Committee and a member of the Senate Republican leadership--have stalled this confirmation needlessly for 3 weeks.

This is one of the 13 judicial nominations reported favorably by the committee to the Senate since June to fill circuit and district court vacancies on Federal courts around the country. Ten of those nominations were reported without a single dissenting voice. This is unfortunately only the third of those judicial nominations to be considered all year.

It is October 21. By this date in the administration of George W. Bush, we had confirmed eight lower court judges. By this juncture in the administration of Bill Clinton, we had likewise confirmed eight circuit and district court nominations. The Senate has confirmed just three circuit and district court nominees this year less than half of those considered by this date during President Bush's tumultuous first year in office and confirmed by this date during President Clinton's first year. This is despite the fact that President Obama sent nominees with bipartisan support to the Senate two months earlier than did President Bush. Moreover, President Clinton's term also began with the need to fill a Supreme Court vacancy.

The first of these circuit and district court confirmations this year did not take place until September 17, months after the nomination of Judge Gerard Lynch had been reported out of committee with no dissent. Finally, after months of needless delay, the Senate confirmed Judge Lynch to serve on the Second Circuit by an overwhelming vote of 94 to 3. That filled just one of the five vacancies this year on the Second Circuit. The Second Circuit bench remains nearly one-quarter empty with four vacancies on its 13-member bench.

Judge Viken, the first of just two district court judges the Senate has been allowed to vote on this year, was confirmed on September 29, by a unanimous 99-0 vote. Today, the Senate is finally being allowed by Republicans to vote to confirm Roberto Lange, who was reported by the committee on October 1. It took 3 weeks to proceed to Mr. Lange's nomination despite the fact that he, like Judge Viken, had the support of both his home State Senators, one a respected Democratic Senator and the other a Republican Senator who is a member of the Republican Senate leadership.

South Dakota has had its two vacancies filled this year but vacancies in 35 other States remain unfilled and the Senate's constitutional responsibilities are going unfulfilled. There was--there is--no reason for the Republican minority to impose these unnecessary and needless delays to judicial confirmations. When will Senate Republicans allow the Senate to consider the nominations of Judge Hamilton to the Seventh Circuit, Judge Davis to the Fourth Circuit, Judge Martin to the Eleventh Circuit, Judge Greenaway to the Third Circuit, Judge Berger to the Southern District of West Virginia, Judge Honeywell to the Middle District of Florida, Judge Nguyen to the Central District of California, Judge Chen to the Northern District of California, Ms. Gee to the Central District of California and Judge Seeborg to the Northern District of California?

In a recent column, Professor Carl Tobias wrote:

President Obama has implemented several measures that

should foster prompt appointments. First, he practiced

bipartisanship to halt the detrimental cycle of accusations,

countercharges and non-stop paybacks. Moreover, the White

House has promoted consultation by seeking advice on

designees from Democratic and GOP Senate members, especially

home state senators, before official nominations. Obama has

also submitted consensus nominees, who have even temperaments

and are very smart, ethical, diligent and independent.

I ask unanimous consent that a copy of Professor Tobias's column be printed in the Record following my statement.

When I served as chairman of the Senate Judiciary Committee during President Bush's first term, I did my best to stop the downward spiral that had affected judicial confirmations. Throughout my chairmanship I made sure to treat President Bush's judicial nominees better than the Republicans had treated President Clinton's. During the 17 months I chaired the Judiciary Committee during President Bush's first term, we confirmed 100 of his judicial nominees. At the end of his Presidency, although Republicans had chaired the Judiciary Committee for more than half his tenure, more of his judicial nominees were confirmed when I was the chairman than in the more than 4 years when Republicans were in charge.

In spite of President Obama's efforts, however, Senate Republicans began

this year threatening to filibuster every judicial nominee of the new President. They have followed through by dragging out, delaying, obstructing and stalling the process. The result is that 10 months into President's Obama's first term, the Senate has confirmed only three of his nominations for circuit and district courts while judicial vacancies skyrocket around the country. The delays in considering judicial nominations pose a serious problem in light of the alarming spike in judicial vacancies on our Federal courts.

There are now 96 vacancies on Federal circuit and district courts and another 24 future vacancies already announced. These vacancies are at near record levels. Justice should not be delayed or denied to any American because of overburdened courts. We can do better. The American people deserve better.

Professor Tobias' observations about the Second Circuit hold true throughout the country and with respect to this President's efforts to work cooperatively with respect to judicial nominations. President Obama made his first judicial nomination, that of Judge David Hamilton to the Seventh Circuit, in March, but it has been stalled on the Executive calendar since early June, despite the support of the senior Republican in the Senate, Senator Lugar. The nomination of Judge Andre Davis to the Fourth Circuit was reported by the committee on June 4 by a vote of 16 to 3, but has yet to be considered by the Senate. The nomination of Judge Beverly Baldwin Martin to the Eleventh Circuit has the support of both of Georgia's Senators, both Republicans, and was reported unanimously from the committee by voice vote on September 10 but has yet to be considered or scheduled for consideration by the Senate. The nomination of Joseph Greenaway to the Third Circuit has the support of both Pennsylvania Senators, and was reported unanimously from the committee by voice vote on October 1, but has yet to be considered or scheduled for consideration by the Senate. All of these nominees are well-respected judges. All will be confirmed, I believe, if only Republicans would consent to their consideration by the Senate. Instead, the President's good efforts are being snubbed and these nominees stalled for no good purpose.

President Obama has been criticized by some for being too solicitous of Senate Republicans. As Wade Henderson, the executive director of the Leadership Conference on Civil Rights, said to The Washington Post recently: ``I commend the President's effort to change the tone in Washington. I recognize that he is extending an olive branch to Republicans on the Judiciary Committee and in the Senate overall. But so far, his efforts at reconciliation have been met with partisan hostility.'' As usual, Wade has it right. The efforts the President has made have not been reciprocated.

The Senate can and must do a better job of restoring our tradition of regularly considering qualified, noncontroversial nominees to fill vacancies on the Federal bench without needless and harmful delays. This is a tradition followed with Republican Presidents and Democratic Presidents. We should not have to overcome filibusters and spend months seeking time agreements to consider consensus nominees.

In addition, four nominations to be Assistant Attorneys General at the Department of Justice remain on the Executive calendar, three of them for many months. Republican Senators have also prevented us from moving to consider the nomination of respected Federal Judge William Sessions of Vermont to be Chairman of the United States Sentencing Commission for over 5 months, even though he was twice confirmed as a member of that Commission. The majority leader has been forced to file a cloture motion in order to end the obstruction of that nomination.

Four out of a total of 11 divisions at the Department of Justice remain without Senate-confirmed Presidential nominees because of Republican holds and delays--the Office of Legal Counsel, the Tax Division, the Office of Legal Policy, and the Environment and Natural Resources Division. Earlier this month, with the hard work of Senator Cardin, we were finally able to move forward to confirm Tom Perez to head the Civil Rights Division at the Justice Department. His nomination was stalled for 4 months, despite the fact that he was approved 17 to 2 by the Judiciary Committee. At the last minute, Senate Republicans abandoned an ill-fated effort to filibuster the nomination and asked that the cloture vote be vitiated. He was finally confirmed with more than 70 votes in the Senate.

During the 17 months I chaired the Judiciary Committee during President Bush's first term, we confirmed 100 of his judicial nominees and 185 of his executive nominees referred to the Judiciary Committee. And yet 10 months into President's Obama's first term, we have confirmed only 2 of his nominations for circuit and district courts and 40 of the executive nominees that have come through our committee.

I hope that, instead of withholding consents and filibustering President Obama's nominees, the other side of the aisle will join us in treating them fairly. We should not have to fight for months to schedule consideration of the President's judicial nominations and nomination for critical posts in the executive branch.

I look forward to congratulating Mr. Lange and his family on his confirmation today. I commend Senator Johnson for his steadfastness in making sure his State is well served.

Mr. President, I will vote against the motion to proceed. Before Senator Lieberman leaves the floor, I want to say again, of all the people I have met in the Senate, he constantly amazes me, because there is no doubt he is doing this because he believes passionately that America is at a crossroads and this is making the problem worse, not better. I am on a bill with him--there are seven Republicans and seven Democrats--that is a comprehensive solution to our health care needs. It is the Wyden-Bennett bill. It mandates coverage, but we do it through the private sector.

I want colleagues to know that Senator Lieberman has been constructive in trying to find a bipartisan compromise that will allow us to deal with health care inflation, which is a problem in the private sector. He practices what he preaches, trying to solve problems. As he explained it, the Senator from Mississippi and I were sitting here talking. There is not much of that around here in politics now, where one would come out and take on an issue that is being pushed by leaders of the Democratic Party. He is an independent Democrat, but he articulated the reason in a way most Americans really appreciate.

Doctors have a problem. In 1997, we tried to balance the budget with President Clinton, the Balanced Budget Act of 1997. When we looked at how we could sustain a balanced budget, we had to go to where the growth was in the budget. The big programs were Medicaid and Medicare, the entitlements. Eventually, those two programs will cost the equivalent of the entire Federal budget today in 20 or 30 years. If we want to balance the budget, we have to slow down entitlement growth.

Medicare is one of those programs that have grown dramatically. When it first came about, it was a $4 billion safety net. They projected that Medicare would cost $37 billion in 1990. It was like $90-something billion. It is $400 billion today. Those who designed the Medicare Program as a safety net for senior citizens without health care did a good thing, but from then until now, it has become a $400 billion item that is eating up the entire budget.

In 1997, we recalculated the growth rates to be paid to doctors and hospitals. Since then, doctors and hospitals have been saying that we cut reimbursements to the point that they can't take Medicare and Medicaid patients and it is hurting their ability to stay in business. About 60 percent of their income comes from the Federal Government. I don't doubt that is true. What we did is just nickel and dime doctors and hospitals and never reform Medicare.

So Senator Lieberman is right. To help doctors and hospitals and the

country achieve a balanced budget, we will have to fundamentally reform Medicare, and the doctor fix should be part of that effort.

What we are doing here is making a promise we can't afford to pay. We are going to tell the doctors: Don't worry ever again about Medicare reimbursements being cut because for a 10-year period, we are going to hold you harmless.

That is beyond cynical. We need to look at the doctor fix in terms of comprehensive Medicare reform. It is a $245 billion item designed to get the medical community to support the leadership version of health care. It is transparent. It is wrong. It is bad politics. It is bad policy. I hope my colleagues will reject it.

The bill coming out of the Finance Committee--and I congratulate Senators who are trying to fix health care because it needs to be fixed--is about an $800 billion expenditure, a little bit more. It is revenue neutral over a 10-year period because it is going to be paid for. Four hundred billion in Medicare cuts are part of the payoff, the pay-fors.

How do we take $800 billion of expense and make it revenue neutral? We offset it. One of the offsets is a $400 billion-plus reduction in Medicare spending over a 10-year window. I argue that not only is that not going to happen because the Congress hasn't reduced Medicare spending anywhere near that, it is just politically not going to happen. Two years ago, we tried to slow down the growth of Medicare to $33.8 billion over a 4- or 5-year period and got 24 votes. If colleagues think this Congress is going to have the political will and courage to reduce Medicare by $400 billion over 10 years, show me in the past where we have had any desire to do that.

The doctors fix is the best evidence yet of what will come in the future. We are contemplating doing away with the reduction in physician payments that was part of the balanced budget agreement because our medical community has been hit hard and is complaining. Look at the $400 billion. Do we think if people are going to be on the receiving and of a $400 billion cut over a period of time, they are going to accept it happily? Do you think they are not going to complain? What do you think we are going to do when one group of the medical community or the insurance community says, ``You are putting me out of business.''

These $400 billion cuts are never going to happen because, you see, with the doctors fix, where every year we relieve the doctors from the imposition of that agreement in 1997--and in many ways we should because the 1997 agreement was not comprehensive--but to those who believe we are going to cut $400 billion in Medicare, have the courage to tell the doctors we are going to do to them what we said we would do back in 1997. Nobody wants to do that, and I am sympathetic as to why we do not want to do that because we are asking too much of doctors and hospitals and we did not reform the system as a whole.

Mr. President, $245 billion added to the debt is no small thing. What I hope will happen is we can find a bipartisan pathway forward on health care reform that deals with inflation, deals with better access to preventive medicine, has some medical liability reform, is truly comprehensive, with give-and-take, and mandates coverage. I am willing to do that as a Republican. But if we go down the road our leadership has set for us here and basically tell the doctors ``Don't worry anymore, you are going to be held harmless for the next 10 years,'' then what group will follow who will want the same deal and to whom will we begin to say no? I do not know. I do not know to whom we will have the ability to say no if we do this. And if you say no to them, what the heck do you tell them--``You are not a doctor, so it does not matter what we do to your business.''

If we do this, we have lost the ability, in my view, to provide the necessary solutions to the hard problems facing the country. We will have given in to the most cynical nature of politics. We will have destroyed our ability to engage with the public at large in a credible way to fix hard problems. And when it comes time to ask people to sacrifice, they are going to look at us and say: What do you mean ``sacrifice?'' Aren't you the people who just basically wiped out what the doctors had to do because you were afraid of them?

I am not afraid of doctors. God bless them. I am glad we have them. What we have done in the name of reform has been unfair because we picked on them and not the system as a whole. So to the doctors out there, Lindsey Graham gets it, that your reimbursement rates as they exist today under Medicare make it very difficult for you to do business. But I hope you will understand that my obligation is beyond just to the doctors in South Carolina; it is to what Senator Lieberman said: the next generation as well as to the here and now.

Every politician has a problem: How do you affect the here and now, people who can vote for you, and how can you secure the future? Well, you just have to ask the people who are here and now to be willing to make some changes for the benefit of the country long term. I am confident that if we ask and we do it in a smart way, people will join with us. I want to give the doctors better reimbursement rates, and the only way we can achieve that is to reform Medicare from top to bottom and make it more efficient.

One of the things I am willing to do is ask a person like myself to pay more. As a Senator, I make about $170,000 a year. I am not saying we are worth it, but that is what we pay ourselves. I would like to think we earn our money because it is not an easy job, but there are a lot of jobs harder than being a Senator, I can assure you. But right now, the system we have to fund Medicare, the trust fund, will run out of money in about 4 years. But basically I am paying the same amount for Part B premiums that cover doctors and hospital payments out of Medicare as my aunt and uncle who worked in the textile mill and made $25,000 a year. I am willing for people like myself to have to pay more to keep Medicare solvent.

We are making some changes but not nearly enough. Mr. President, $3 out of $4 of Medicare spending comes from the General Treasury, the taxpayers. One-fourth of the money to cover Medicare expenses comes from the patient population being served. There are plenty of Americans who are paying about $100 a month once they get into retirement who can afford to pay $450 a month for the Medicare services they receive. Nobody is asking them to do it. I am willing to ask, and I am willing to do it myself. It is those types of changes that will lead this country to a brighter future and will correct the imbalance we have.

Finally, Medicare is $34 trillion underfunded. If you had $34 trillion sitting in an account today, it would earn interest over 75 years. You would need all the money--the $34 trillion plus the interest--to make the payments we have promised people in the future.

When I was born in 1955, there were 16 workers for every retiree. Today there are three, and in 20 years there will be two. There will be two workers paying into the Social Security and Medicare trust funds where there used to be 16 when I was born. There are more baby boomers retiring every day than anyone ever anticipated. We are living far beyond 65.

The question for the country is, Will people in my business go to you, the public, and say change is required? We cannot run the system assuming things that do not exist. We have to come to grips with the fact that we have an aging population, we live longer, there are more retirees than ever, and there are fewer workers. Once we come to grips with that dynamic and ask those who can afford to give, to give--hold those harmless who cannot afford to give--America's best days are ahead.

If we do not reform these systems and we continue to do what is being proposed today--try to buy a constituency off: Doctors, we will fix your problem if you will support our bill; the $254 billion it will cost to get you onboard, do not worry about it.

To the doctors who may be listening, you better worry about it. You need to worry about not only the viability of your medical practice but the ability of your government to make payments it has promised to the next generation, the ability of your government to be able to continue to operate, the ability of our country to pass on to the next generation a sound and secure America.

We are about to borrow ourselves into oblivion. There is a theory out there, long held, that democracies are doomed to fail because democracies over time will lose the ability to say no to themselves; that we in the government will continue to grow the government based on the needs of the next election cycle and make promises that make sense for our political future but really over time are unsustainable. We have reached that point, and we are about to go over the edge.

The only way America can self-correct is to make sure our political leadership is rewarded when we ask for change we can believe in. This is not change we can believe in. This is the old way of doing business. This is buying off a constituency that is important for the here-and- now debate of health care and not giving a damn about the consequences to the country down the road. This is how we got in this mess.

If we pass this bill, not only have we destroyed this new hope from a new President of ``change we can believe in,'' we will have reinforced the worst instincts of politics, sold the country short, and made it impossible to say no to the next group we want to sacrifice who needs to help us solve this problem.

With that, I yield back.

I suggest the absence of a quorum.

Mr. President, fixing a system so badly damaged by decades of mismanagement and manipulation is not an easy task. It is no secret that health care is no exception.

We are not doing it simply to keep us busy; that is, legislate on health care. We have a bevy of other backbreaking problems that have piled up over the past 8 years--everything from energy, to education, to Wall Street abuses--only to be passed on to this Congress and the Obama administration.

Nor are we doing it because the health insurance industry wants us to do it; just the opposite. In fact, they are doing all they can to protect their reckless policies and raging profits.

We are doing this legislating on health care because the American people demand that we do it. Families of all backgrounds and from every State are counting on us to act. Last November, it was one of the primary reasons they called on Democrats to correct our country's course.

The American people are closely watching this debate. They are listening to the policies being proposed, and they can see the strategies employed toward those ends. They are watching, and here is what the American people are saying in response: Nearly two-thirds of them know Republicans are not working in good faith with Democrats to reform America's broken health insurance system.

They are right. While we have made every effort to create a good bill that can earn the support of as many Senators as possible, Republicans have made every effort to stop any bill, regardless of what is in that bill.

How do we know this? We know this because Republicans have offered no ideas for reform. We know this because while they talk in the abstract about proposals, they have yet to offer any of their own. But, most of all, we know this because Republicans say it themselves.

In August, the junior Senator from Arizona predicted that almost all Republicans would oppose health insurance reform, regardless of any concessions Democrats made.

Then the senior Senator from Oklahoma said--and I quote--

I don't have to read it, or know what's in it. I'm going to

oppose it anyways.

Then I opened this morning's Roll Call newspaper--this newspaper that covers Congress--and read a disturbing headline, one that confirms what nearly two-thirds of the American people already know and should convince the rest. It reads: ``GOP Launches Strategy to Trip Up Health Bill.''

If Republicans truly want to legislate, shouldn't this headline read ``GOP Launches Strategy to Improve Health Bill''? Wouldn't we all benefit from the GOP launching a strategy to strengthen the health bill? Wouldn't it be better for the millions who fear losing their health insurance, and for the millions who do not have any to begin with, if we would open the morning newspaper and read even this: ``GOP Launches Strategy to Contribute to Health Bill''? But, no, none of that.

The truth is that they have no interest in improving or contributing to health reform and strengthening it or contributing to its improvement in any way. Instead, Republicans have one strategy--and one strategy alone--support the broken status quo.

Republicans want to ``trip up'' our plan to protect what works about the system, fix what does not, and help the middle class get ahead. That is because they do not mind the fact that insurance companies can deny you coverage when you need it the most or because you have a preexisting condition, defined as anything from high cholesterol to hay fever to heart disease to diabetes.

Republicans want to ``trip up'' our plan to stabilize health insurance for those who have it and help secure it for those who do not. That is because they think it is OK for insurance companies to raise your rates just for getting old or because your dad had prostate cancer or because you are a woman.

Republicans want to ``trip up'' our plan to keep the insurance industry honest and to protect Medicare. That is because they support a status quo that forces families fortunate enough to have health insurance to pay an extra $1,000 or more every year to cover all other families who have none.

Republicans want to ``trip up'' our plan to lower costs for families and make sure every American can afford good quality care that can never be taken away. That is because they simply do not have any ideas for helping the American people--even people in their own States--who are suffering so desperately.

Republicans will do everything in their power to stop reform this time because for many on the other side, there will never be a good time to reform health insurance.

That is not what our constituents sent us here to do, and that is not how to legislate.

I spent this past weekend in Nevada and heard firsthand from people who are suffering. Today we learned our State's unemployment rate rose again. One example: It is not a bunch of people out of work or people who do not have good jobs who are complaining about health insurance. I did an event in a hotel in Reno, NV--the largest and I think probably the most successful resort in northern Nevada. Of course, when I asked for questions, a number of the questions dealt with health care.

As I walked out, the owner of the property walked alongside of me and said: Senator, I want you to know that other than my cost for personnel--my wages for my employees--health care is the one issue that is so hurting my business, health insurance for my employees. I am going to keep it, but it is so difficult for me to do so.

Here is a man who has probably 1,500, 2,000 people who work for him. Think what it is like for someone who has 25 or 50 or 75 or 100 people. If someone who has the buying power of a couple thousand is having difficulty, think what it is like for people who do not have that buying power.

So this past weekend in Nevada, I really did hear from people who are suffering. Today, we learned that our State's unemployment rate rose again--another tenth of a percent. That tells me we do not have time to waste with people looking to ``trip up'' recovery. Instead, we need legislators willing to work with us toward solving problems.

Here is an opportunity. Republicans can show they are willing to do more than simply stand in the way. We are working this week to protect seniors' relationships with their doctors. One of the biggest fears of seniors is that their doctors will drop them, which is why we are proposing a bill to make sure doctors will continue to see their Medicare patients.

This is a very serious issue. It is not one that is made up. There are ads running around the country today. There is one that says: ``If You Don't Pass S. 1776, Seniors Will Lose.''

Seniors count on their doctors to get the care they need to

stay healthy. The Medicare Physician Fairness Act (S. 1776)--

That is the legislation I am talking about--

preserves the doctor-patient relationship and protects

seniors' access to their doctors. AARP is fighting to ensure

that doctors will continue accepting patients on Medicare.

Ninety percent of AARP members agree with this. This is a real problem. Because of some of the things done with Medicare legislation in the past, a number of doctors have decided they cannot afford to take Medicare patients. This will drive another 40 percent of the doctors away from Medicare. It will destroy Medicare. So it is important we work together to get something done to take care of this. That is because the status quo simply will not work.

We are working, as I said, this week to protect seniors' relationships with their doctors. One of their biggest fears is that their doctors will simply drop them, which is why we are proposing this bill to make sure doctors will continue to see Medicare patients.

Republicans have come to the Senate floor numerous times in recent weeks to demand that Congress protect seniors. This so-called doctors fix that AARP is running the ads about is an opportunity for Democrats and Republicans to work together to improve Americans' health. This time it is seniors' health.

The AARP has 40 million members. Nine out of 10 of them support this legislation--90 percent of them. I hope Republicans will listen to the very people whom they claim to defend and support--seniors.

While, generally speaking, the Republican strategy is disappointing, to say the least, it is not entirely surprising. After all, one Republican Senator--I do not know if he is speaking for the entire Republican Senate--is on record hoping health insurance reform will be President Obama's ``Waterloo.'' Nor is it inconsistent with the obstructionist tactics that have denied and delayed so many other important efforts to address so many of our critical challenges.

Democrats have been consistent in our efforts to reach across the aisle. In April of this year, just as the health care debate was beginning, I wrote my counterpart, Leader McConnell, to express my great hope that Republicans would work with us in this important and historic endeavor. We have an opportunity this week to fulfill that request I made. Here is what I wrote on that occasion:

In order for this bipartisan process to take root,

Republicans must demonstrate a sincere interest in

legislating. Rather than just saying no, you must be willing

to offer concrete and constructive proposals.

I concluded the letter by writing:

I hope your conference will recognize that this issue is

too important to be manipulated for political purposes.

So it is now about a half a year later. It is clear Republicans have not heeded our gesture. It is equally clear to the American people, two-thirds of whom readily recognize that Republicans have no interest in returning the favor--not in the least.

As former Senate Majority Leader Bob Dole said a few days ago--and I quote--

Sometimes people fight you just to fight you.

That might be true, but it will not be tolerated. Congress will not be sidetracked by those who devise strategies only to ``trip up'' progress, rather than to contribute in good faith. This country has no place for those who hope for failure.

Mr. President, I suggest the absence of a quorum.