Dominguez-Escalante National Conservation Area and Dominguez Canyon Wilderness Area Act

Mr. President, I will vote for the motion to proceed. That gets us to the point at which we can have the bill before the Senate in order to debate and to amend the legislation. It is a debate we must have. It is a debate we cannot afford not to have.

I ask unanimous consent that I be able to proceed for 2 minutes.

I will vote for the motion to proceed to bring the legislation before the Senate. This is a debate we must have. It is a debate we cannot afford not to have. What is before us is to make health insurance available and affordable. The legislation that will come before us will prevent someone from being denied insurance because they have a preexisting condition. It will not allow the insurance companies to cancel policies because someone is sick. It will bring in millions of uninsured people who will then be able to have insurance and can afford it. By the way, that brings down the cost of all the rest of our premiums because they get health care at the emergency room, and guess who pays. All the rest of us do, to the tune of a national average of about $1,000 per policy. This legislation will reduce the deficit, $130 billion over the next 10 years and over $650 billion in the second 10-year period. There is room for improvement. That is why we need to debate it. That is why we need to amend it. I will be offering an amendment that will produce savings to the taxpayers of another $100 billion by lowering the cost of drugs to Medicare recipients. Let the debate begin. I look forward to it.

Mr. President, I rise to support the majority leader and his motion for cloture to cut off debate to allow us to vote on the motion to proceed which will allow us, then, to get the bill to the floor so that we can debate and start amending this bill. I wish to use the next several minutes to lay out a comprehensive reason of why this Senator supports moving to take up this legislation.

I look forward to the amending process, and there will be vigorous attempts to amend it. I had offered a number of amendments in the Finance Committee. Most of those amendments were, in fact, adopted, but there was one in particular that was not adopted on a vote of 13 to 3. It would save the American taxpayers $109 billion by having the price of drugs that are sold to Medicare recipients under the Medicare Part D who also are eligible for Medicaid but get their drugs under Medicare, it would cause those drugs to be sold at the same discounts that they get the drugs under Medicaid. There have been discounts for a couple decades because of the bulk purchases of millions and millions. It is close to 50 million people who get drugs under Medicaid. There are about 43 million people who get their drugs under Medicare.

Let me correct that. There are 43 million people on Medicare. There is some number less than that who are now getting their drugs under Medicare Part D. But, in fact, they don't get the same discounts that those very same people in Medicaid would get, even though they are eligible for those discounts. Those people are called dual eligibles because they are eligible because they are poor to get it under Medicaid, but they are also over 65. Therefore, dual eligibles should be able to get cheaper drugs. No, we can't do that. Because in the Medicare prescription drug benefit passed 6 years ago, those kinds of discounts were not allowed.

That is a huge additional cost to the taxpayers. The overall amount of Medicare drugs being sold, if you got those discounts, would be something in excess of saving the American taxpayer $200 to $250 billion. For those who are dual eligible--they qualify for Medicaid but get their drugs under Medicare--the savings would be $109 billion.

This Senator is going to offer that amendment. It is a high threshold of 60 votes that we have to get but, indeed, we will see and on down the line.

Why am I insisting on continuing to offer this? Well, it is interesting that just recently an AARP study has come out, along with another study called IMS. They have noted that the cost of drugs, brand name drugs, their wholesale prices have increased, in the year 2008, 9.3 percent. Contrast that to the rate of inflation, which was about zero percent. So you see that the cost of drugs is continuing to go up. It is time to give our people some relief.

We could do a lot with that extra $109 billion. First, we could lower the deficit by $109 billion. So whereas this bill brought forth by the majority leader saves the Treasury money over the 10-year period and reduces the deficit by $130 billion, we could add another $100 billion to that. We could be lowering the deficit $230 billion. But we could take part of that money that we would save the taxpayers and use that to fill the doughnut hole.

That is the strange creature in statute that gives senior citizens under Medicare some reasonable compensation for their drugs, up to a certain level. That level is, generally, between about $2,500 and $4,500 of total drug purchases within a year. But once they get into that zone, that doughnut hole, in fact, they get no assistance from Medicare. That is called the doughnut hole. We could help senior citizens fill that doughnut hole so they are not bearing the full cost of those drugs when they get hit with huge drug expenses in a particular year.

We will see what the will of the Senate is as we come out here and start to vote.

The reason it is important, tomorrow night at 8, for us to get 60 votes to shut off debate is so we can go to the motion to proceed to get this bill to the floor. The reason is we need a debate. We

can't afford not to have a debate. In what is known as the world's most deliberative body, that is what we do--debate and amend and try to perfect. Is anyone denying that health care, the cost of health care, the availability of health care, the availability of health insurance, the availability of health insurance at a reasonable price, is anybody disagreeing that is not a problem? Our people are hurting.

One of the main purposes of bringing this legislation out here and trying to find a reasonable solution is to make health insurance and health care available and affordable.

For example, what about if you have a preexisting condition. You can't get health insurance. We are going to change that in this legislation.

What about if you are sick and your insurance company suddenly comes and says: We are going to take away your insurance, we are going to cancel your health insurance. Is that a good outcome? There is nobody in America who thinks that is a good outcome. That is what we are trying to change. By the way, that is what the bill proposed by the majority leader will, in fact, do.

What about all those 46 million people who don't have health insurance? First of all, a lot of those folks do get health care, but where do they get it? They get it at the most expensive place at the most expensive time. They go to the emergency room, after what could have been very possibly prevented becomes an emergency. So it is at the most expensive place at the most expensive time. By the way, guess who pays. Do you think all those costs suddenly evaporate in the ether? No. They are costs in a hospital that are ultimately borne by all the people who support the health insurance system; that is, those who have health insurance policies and pay premiums. It is no small amount that we pay. As a matter of fact, nationwide, the additional cost to a family health insurance policy to take care of uninsured people is between $900 and $1,000 per year extra. It is a hidden tax on all the rest of the people who are paying their health insurance premiums.

In my State of Florida, it is even higher. It is estimated to be $1,400 per family policy per year, a hidden tax. That is a hidden tax that will disappear, if we can bring in those 46 million people nationally who are uninsured, 4 million of whom are in Florida, if we can bring them into the system. Will we bring them into the system? The bill the majority leader has put on the table will cover 98 percent of all Americans with health insurance. That is the entire spectrum of Americans who receive health care. Is that worthwhile doing? I certainly think it is.

I said at the outset this bill also tries to approach this in a responsible financial way. The actual cost of the bill is about $848 billion over 10 years. But that $848 billion is more than paid for because, at the end of that 10 years, there is an additional $130 billion that is left over. That is surplus that will go directly to lower the deficit. The projection by the Congressional Budget Office for the second 10-year period is at least a $650 billion reduction of the budget deficit in that 10-year period and possibly as high as $1 trillion in lowering the deficit.

What does that tell us? What it tells us is that one of the reasons we need a bill coming out on the floor is that not only do our individual Americans have difficulty paying for the cost of health care, the U.S. Government is having difficulty paying for the cost explosion of Medicare.

Unless we start getting those costs under control, then, in fact, we are going to be in an unsustainable proposition with Medicare. A system of revising health delivery capabilities so people are not being canceled, no preexisting conditions, people can get health insurance at affordable rates but at the same time starts lowering the overall cost to not only individuals but to the U.S. Government, it seems to me that is desirable.

So you will hear and we have just heard comments about how Medicare is going to be cut. Well, there are clearly inefficiencies in Medicare that need to be wrung out. Let me give you an example. Right now, we have what is known as Medicare fee for service. It basically pays the doctor's bill that is submitted for the person who is eligible for Medicare. But what happens is, the Medicare patient goes to this specialist, that specialist, that specialist, and all of them are not talking to each other. This one orders this particular set of tests, and that one, because he does not know what the other one is doing, is ordering the same test, but Medicare is getting all of the same bills. This bill, in reforming health care delivery, is going to try to get at that. It is going to set up accountable care organizations. It is going to set up electronic records so there is no more of this shifting around and, oh, I didn't get the report. It is going to be there available immediately. These are obvious technology increases we have to do. That is Medicare fee for service.

How about a program called Medicare Advantage? Let me tell you what Medicare Advantage is. Medicare Advantage is a fancy word for a Medicare HMO. Do you know what an HMO is? An HMO is an insurance company. It was originally designed in the late 1990s that you could deliver health care cheaper to senior citizens in Medicare through an HMO. So when it was first set up, Medicare HMOs were given 95 percent of fee for service because they were going to save costs. They were going to save costs to the individual, they were going to save costs to the government--95 percent.

But, lo and behold, in 2003, in the Medicare prescription drug benefit, it not only set up what I described a while ago as this unusual doughnut hole and drugs that cannot be discounted to the Federal Government when it is buying drugs in bulk for millions of Medicare recipients, it also set up that we are going to give a cushy arrangement to insurance companies where insurance companies that want to sign up Medicare recipients are going to get 14 percent more per patient--114 percent instead of 100 percent of Medicare fee for service. Is it any wonder costs are exploding in Medicare if suddenly a program gets 14 percent more per patient than what the standard baseline ought to be, which is Medicare fee for service? It does not take a rocket scientist to figure that out.

Because insurance companies--Medicare HMOs; the fancy name is ``Medicare Advantage''--because they get more, 14 percent more, then they can offer additional things to the senior citizens, and this has proved to be quite popular. Basically, 30 percent of all Medicare recipients in my State of Florida have signed up for Medicare Advantage. Indeed, the biggest thing they have that is desirable--you hear about eyeglasses and hearing assistance and so forth, but the biggest thing that is the most popular is that because the insurance company is getting paid so much more per person, it can then use part of that money to pay the copays on Medicare, such as Medicare hospital insurance, Part A and part B, as well as Part D, the drugs. So it is very popular.

So what I said in the Finance Committee is--obviously, we ought to reform the system. And I can tell you, this Senator did not vote for it 6 years ago, which set up this system, which was a cushy system for insurance companies as well as the drug companies. But the fact is, we have not.

So this Senator said, in the Finance Committee: All right, what I want to do is I want to grandfather the people who have it in Florida so that, on a going-forward basis, when this takes effect--in this bill, it takes effect in 2013--when it takes effect, it is only those new people signing up who will operate under the new system that will make it more streamlined but that those who have the existing benefits from Medicare Advantage will not be cut. I offered that amendment along with other Senators in the Senate Finance Committee, and that amendment was adopted.

So the statements that have been made on this floor about Florida Medicare Advantage recipients being cut in Florida is not accurate on this bill. I fought for that. Everybody knew I fought for that. And of the 949,000 Medicare Advantage recipients in Florida, at least 800,000 are operative under the formula we put in and the remaining 149,000 virtually would not be affected anyway. I cannot speak for the other States, but I can sure speak for Florida. That is in this bill. Those other Senators who offered the amendment with me in the Finance Committee had things that tended to their

States, as well, that were part of that amendment. But that is what the situation is with regard to this legislation.

Let me say that if we can get this legislation out of the Senate and get it to a conference committee with the House, the House has a whole different approach. The House works on streamlining Medicare Advantage from the basis of not something known as competitive bid, which is in the Senate bill, but what is known as fee for service, as the target benchmark. That does not have the Draconian cuts, in my opinion, to many of our Medicare Advantage recipients.

But I want the record clear here that with regard to Florida, Florida Medicare Advantage people have been grandfathered in of those who are in existence and those who still will be in existence having signed up for Medicare Advantage until the date at which the new system would start.

I see we have changed Presiding Officers, and it is such a pleasure to have the esteemed Senator from Minnesota in the chair. Madam President, there is room for improvement. We spent 2 full weeks in the Senate Finance Committee on amending this legislation. We had spent 3 months prior to that discussing it. You can imagine, in a nation as diverse and complicated as ours and a health care industry where everybody and his brother and sister have their fingers in the pie, how complicated this is. But that is the reason for the amendatory process: to improve, to perfect.

I want to wind up my remarks by giving a picture of the totality. We have had so much of the debate, ever since summer, dominate on the concept of a public plan. Many organizations have now come out and said that a public plan, at max, is going to affect 4 million or 6 million people. If it affects 6 million people who sign up for a public plan-- if there is one in existence. And, of course, the majority leader has in here not one that is mandatory. He has it as an option where a State can withdraw from having a public plan. But if the max of 6 million people signed up on a public plan, that is 2 percent of the entire country. Yet you would think that was the only thing when you listen to the arguments--and sometimes we watched fights in these townhall meetings back in the summer--you would think that was the only thing this whole health care reform was about. In the max, it is going to affect 2 percent.

Why is that? Why is it that it only affects 2 percent? Well, look at the whole population to whom we want to give health care delivery.

Take my State of Florida. Approximately--and I am rounding these numbers--approximately 50 percent of our people in Florida get their health insurance from their employer and they are in a group policy. Another 16 percent in my State get their health care from Medicare because they are eligible at their age. Another 10 percent in my State get their health care from Medicaid because they are either qualified under the income level or they are disabled. Now add that up. That is 76 percent right there of all the people of Florida. That includes children. OK. What about the remaining 24 percent? About 4 or 5 percent of our people also have health insurance but they pay through the nose because they are buying it as individuals as opposed to a group policy. If you are buying it individually, where all the health risk is on one life, the cost of those premiums is very high. The remaining 19 percent are the uninsured. That is as to the population of my State of Florida. That will vary with different States. Obviously, in Florida we have more people aged 65 and older and therefore eligible for Medicare than most States.

But you can see now that what we are going to do is, over here for this remaining 24 percent, we are going to set up a health insurance exchange. In the case of Florida, it is going to have potentially 4 million people in it. It is going to be the uninsured who are now going to have access to health insurance with no preconditions, and they cannot cancel their policies, and it is affordable. It is also going to be available to those people who, in fact, have policies they cannot afford, usually the individual policies. There will be some small business employers--for example, those with 50 employees or fewer--who will not be offering health insurance, and their employees will, for the first time, be able to go to the health insurance exchange and be able to get health insurance.

All right. The competition in that health insurance exchange is going to have a public plan, if a State approves. That is why it comes down to such a small percentage. That is why an issue has dominated the debate but is not the main issue. The main issue of this legislation is to provide health insurance and health care to our people that is available and affordable.

I will close with this: We have all heard these stories because people have been coming to us in our townhall meetings, on the phone, in the airport, back during the parades, at the meetings, and they have been telling us these very tragic stories: the woman who is in the middle of chemotherapy and suddenly gets a cancellation notice from her health insurance company; the person who desperately needs health insurance and can't get it and who has had it for some period of time; the person who is hanging on for dear life to that job because that job they have is not only their means of financial remuneration but is also their ticket to having health insurance.

These are the tragic stories we want to change. We want to make people's lives better. We have to start somewhere. That point of starting is going to be at 8 o'clock tomorrow night, Saturday night, because the Senators are going to parade on this floor and indicate yea or nay on whether we are going to shut off the filibuster in order to get to the motion to proceed which will then allow us to get to the bill after Thanksgiving.

It is absolutely essential for the sake of our people that we bring this legislation to the floor and that ultimately we get a product we can pass and get it on to a conference with the House and have an agreement that the President can then sign into law.

Madam President, I yield the floor.

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

Mr. President, the debate has now begun on the bill we call our health care reform bill. It has taken us a long time to get here. After a lot of hearings, a lot of markup, a lot of public discussion, a lot of town meetings around the country, now we are at the final pivotal moment, a historic moment in the long march to pass meaningful health care reform.

I say long march because it started with Theodore Roosevelt and continued on through the New Deal, continued on to Harry Truman's administration, and on to this time. Every time we have been turned back by the status quo forces, those who want to stick with what we have, those who are afraid of making changes. This time they are not going to stop us. This time it is unstoppable. We have come this far, and we are not going to turn back.

Just listening to a little bit of the discussion on the Republican side today and listening to what the Republicans have had to say about health care reform in the last few months and anticipating what we will hear from Republicans in the next few weeks, it will be a message of fear that somehow by changing the status quo, the American people are going to be worse off than they are now, that somehow we are going to take away something they have, that somehow if we just stick with what we have, everything will be fine. But you will hear a lot of words and messages from the Republican side meant to frighten people, to put a pall of fear over what we are trying to do.

The frightening thing for the American people is if we do nothing, if we stick with the status quo. Too many people in this country have no health insurance whatsoever. Thousands every day in this country, every single day thousands of people lose health care insurance coverage. So many people who have preexisting conditions cannot get coverage at all. People who are beginning to retire but they are not quite 65 and cannot get on Medicare are left in a state of limbo, where they cannot get health care coverage.

So many people in this country are being discriminated against in health insurance because--well, because they are a woman or perhaps because they are older, perhaps they are a person with a disability. For a variety of reasons, they are being discriminated against in health insurance coverage.

We have to make these changes. We cannot continue to spend over the $2 trillion a year and still be so lacking in the essential health care services for the people of this country. We spend twice as much in this country on health care as Europe. Yet we have twice as many people sick with chronic illnesses. That does not seem to make sense.

We have some of the highest of high-tech medical devices and procedures and interventions anywhere in the world and, of course, people who have a lot of money in other countries--we always see kings and princes and wealthy people from other countries come here. They come here for the very high-tech, high-cost interventions. We are very good at that. We are the best. We are unequaled in that. But where we fall short is helping the very broad mass of American people to have the peace of mind knowing that if something happens to them, if they do get ill, they are not going to lose everything.

The single biggest cause of bankruptcy--I know in my State of Iowa and I think most of the country, the single biggest cause of bankruptcy is because of medical expenses because people bump up against lifetime caps or annual caps, they cannot make it, and they declare bankruptcy. In no other country in the world is this allowed to happen. It is incumbent upon us to get this bill through.

At the beginning, I wish to salute our majority leader Harry Reid for what he has done. We had our bill that came out of the committee that I am now privileged to chair after the untimely death of our esteemed colleague and friend, Senator Ted Kennedy. Our HELP Committee bill came through under the great leadership of Senator Chris Dodd. We passed it on July 15. Then the Finance Committee, under the able leadership of my friend and classmate Senator Max Baucus of Montana, did their work. Then the two bills had to be put together and that was done by the majority leader and he did a masterful job of putting the two bills together and getting it down to the Congressional Budget Office and getting a score on what it would cost, what it would cover. When we saw the bill come back--the bill we now have in front of us, the so-called merged bill--it truly is a work of genius by the majority leader.

I said the other day that he has the patience of Job, the wisdom of Solomon, and the stamina of Sampson to get this job done.

I also salute all the Senators--Democrats and Republicans--whose ideas are incorporated in this bill. It is a robust bill. It went through a long, bipartisan process. In our committee, we had proceedings that spanned 13 days, 54 hours. Republicans were full- fledged participants. They offered 210 amendments. We accepted 161, many of them making substantive changes in the bill.

A similar open and inclusive process was followed in the Finance Committee. I daresay, when we got our bill through, after all that, after all the

amendments offered, accepted or adopted, not one Republican would vote for our bill--not one. It is truly unfortunate now that we have put these bills together, we have gone through this long process that has taken most of this year, that Republicans have now chosen the path of delay and filibuster and obstruction.

Why are we even here today? We are here because the Republicans are trying to prevent us from even bringing the bill to the floor for debate. How many people in America know that? The reason we are here is because the Republicans do not even want to bring the bill to the floor for debate and amendment. That is their right under the rules of the Senate. It is their right. They can filibuster. They can delay. They can obstruct. They can say no. But just as surely as that is their right, it is our responsibility, as Democrats, to move this bill forward.

I remind my colleagues on the other side of the aisle that last year voters overwhelmingly voted for Barack Obama to make changes, and one of the changes he campaigned so hard on was changes in the health care system and, just as surely, voters elected Democrats to majorities--big majorities--in the House and the Senate to do the same thing. So it is our responsibility to lead, and that is what we are doing now by bringing this bill to the floor. We are taking another giant step toward fulfilling the mandate--the mandate--the people of this country gave to President Obama and the Democratic Party last November to undertake a comprehensive reform of America's health care system.

As not only the long debate has made clear to the American people, but innately the American people know and they understand the current system is hugely dysfunctional, it is wasteful, and it is abusive. People are aware of the abuses that have become standard practice in the health insurance industry: denied coverage because of preexisting conditions; health insurance being dropped because they get sick; their insurance premiums jacked up 100 percent, 200 percent in a year simply because they had an illness.

People know they can be charged higher rates simply because they are a woman. We know, we have the data. Woman, man, same age, same occupation, same status--a woman is charged more than a man for the same policy or they are charged more if they are older. We know about annual caps and lifetime caps I just mentioned that cause people to go into bankruptcy.

The bottom line is this: Every American family knows that in many cases, they are one illness away from financial catastrophe. If you want to talk about fear, that is what people are afraid of, not so much of getting sick--that is part of life--but the fact that illness will drive them to financial ruin, that they will not have enough money to take care of their kids, to send them to college, or to take care of themselves in their old age to supplement their Social Security because the money will be used for an illness.

As I said earlier, 62 percent of U.S. bankruptcies are linked to medical bills. What is the kicker in this is that 80 percent of those were people who actually had health insurance, but they ran up against their lifetime cap. Abuses, abuses by the health insurance industry because they can do it and they can get by with it.

Think about it this way: Health insurance companies employ armies of claims adjustors who routinely deny requests for medical tests and procedures. Why do they do that? Because they get bonuses by saying no to the policyholder. Think about that. An insurance company says to their claims adjustors: We will pay you more the more people you deny. What a system. It is outrageous. It is intolerable, and we cannot afford to let it go on any longer.

One of the many things we do in this bill is to crack down on these health insurance companies' abuses in a very strong and robust way. Again, I deeply regret that our Republican colleagues refuse to join us in this reform effort. They have chosen to defend the status quo, protect the insurance companies and their profits over the health of the American people.

Indeed, my friends on the Republican side and the health insurance companies are now joined at the hip--same talking points, same distortions, same untruths about this bill, same bogus, cooked-up studies, the same determination to obstruct and kill any health care reform effort.

As I said earlier, this time they will not succeed. The more the American people learn about this bill and what is in this bill, the more they like it and the more they are demanding that we get the job done.

President Obama pledged that we would do health reform and not add to the deficit. We have done that with this bill. The Congressional Budget Office says this bill will actually reduce the deficit by $130 billion next year and by $650 billion in the next decade--$650 billion--and it will reduce the deficit continually every decade thereafter. All the budget concerns have been put to rest. Now we can focus on what is in the bill.

The Congressional Budget Office says our bill will cover 94 percent of the American people; 94 percent will now be able to have the peace of mind to know they have health insurance coverage.

Our bill says if you have a health care plan that you like and that you want to keep, nothing will disturb that--nothing. You can keep whatever plan you want if you like it.

A lot of people say this plan doesn't go into effect until 2014. It does take some time to get these exchanges and things set up, but there are some immediate things that will happen next year, and the American people ought to know what that means. For example, our bill right now would ban lifetime and excessive annual limits on coverage next year-- not 2014 or 2015, next year. Think about that in your own policy. Your policy, I guarantee, has some kind of lifetime cap or annual caps. Next year, they will not be able to do that any longer.

Our bill bans rescissions. What that means is that right now so many people don't know that their health insurance policy can drop them. There is a clause in it that says that when you are up for renewal, they can drop you for any reason. The reason they use is, if you get sick. Think about that.

I can't tell you how many people I have talked to in my State of Iowa who have come up to me, especially during the town meetings we have had this summer, and have said: I like my health insurance policy. I have a good policy, and I would like to keep it.

My rejoinder is: That is fine, but I want to ask you a couple of questions. What is your lifetime or annual cap?

Most often, people say: I don't know.

I say: Do you have a lifetime or annual cap in your policy?

They aren't certain.

I say: Do you have a rescission clause in your policy?

I can tell you 100 percent of the people I have talked to said: What does that mean?

I said: What it means is, if you get sick, if you have to have a kidney transplant or if you have cancer or heart disease, can your insurance company drop you when your policy comes due, with no explanation whatsoever?

They don't know.

I said: You have to look at your policy and find out, because most policies have those rescission clauses.

I daresay, when a lot of people say they have a good health insurance policy, they answer yes, they do have a good health insurance policy, as long as they are healthy. As long as you are healthy. Once you get sick, out the window it goes because you have a cap, either a lifetime or an annual, or you have a rescission clause.

The other thing I hear from a lot of families: You know, my kids were covered when they were in school. They are now out of school, they have not quite gotten a job yet, and I can't keep them on my policy and it costs a lot of money to put them on a different policy.

Our bill says that now these young people can stay on their family policy until they are age 26. This is a huge benefit to working families.

I have said many times that the two biggest winners under our health care reform bill are small businesses and the self-employed. Small businesses--we are in a deep recession. If we want to get out of that recession, we better start focusing on small businesses because it is small businesses that create over 65 percent of the jobs in this country. Yet small businesses are thwarted in their effort to expand and grow. One

of the biggest reasons is because of the cost of health care for their employees. So many small businesses now have dropped health care coverage for their employees because they simply cannot afford it or the premiums have gone up, the deductibles are huge, and basically what it has gotten to be is basically catastrophic coverage for their employees. Small businesses need help in order to grow and expand and get us out of this recession. This bill will provide immediately, next year, up to a 35-percent tax credit for health insurance policies for their workers. That is a big deal. It is not just for small businesses, it is for my farmers and for those who are self-employed--for so many self-employed in this country, next year, a tax credit of up to 35 percent.

Next year, we are going to have a new policy option for people who have preexisting conditions. So if you had an illness in the past, if you have been living with cancer and you have it under control, you have a chronic illness, next year we are going to provide a new policy option to put people like that into a high-risk pool and provide that they can get insurance coverage at prices they can afford. When the exchanges come on in 3 years, all of that will go by the wayside. They will not be able to discriminate because of preexisting conditions. But next year, right away, people who have preexisting conditions can get policies at prices they can afford.

How many times do I hear people tell me: Here I am, I have been working hard, I have been a construction worker, or something like that, that is hard work. I am 55. I have had some accidents. I have a bum leg and my back is bad. I can't work until I am 65. But what am I going to do about my health insurance?

We have in here, starting next year, if you are an early retiree, we have a program to protect your coverage and at the same time reduce your premiums, both for you and your employer, until the time you get to be age 65. This is a big deal for so many people in this country.

Last, in whatever time I have left--parliamentary inquiry: How much time does the Senator from Iowa have left?

Madam President, I understand my friend from North Dakota wishes to speak. I will wrap this up by saying there is one other part of this bill that is so important that doesn't get much play but I consider to be one of the most significant parts of this bill, and that is an emphasis on prevention and wellness, keeping people healthy in the first place.

There is a lot of talk about bending the cost curve and how we are going to bend that curve and get costs down. I submit that not only the best way but perhaps the only way we are going to do this is by keeping people healthy in the first place, putting more emphasis on prevention.

I have often said that we don't have a health care system in America, we have a sick care system. If you get sick, you get care. Almost all of our expenditures go for interventions and patching and fixing and mending once somebody gets sick. Very little goes for prevention. About 96, 97 cents of every dollar goes for taking care of you after you get sick. Only about 3 or 4 cents goes to prevention. It is time to do more for that, time to do more for prevention and wellness, keeping people healthy in the first place.

In this bill, we have a provision that says that if you want to go in for your annual checkup and your annual screening, no copay, no deductions, and for certain other screenings, such as colonoscopies, breast cancer screenings, and things like that, no co-pays, no deductibles.

In the ensuing days and weeks when we debate that, I will be talking a lot more about the prevention and wellness part of this bill. It is big. It is the first time we have ever done anything like this, to begin to move the paradigm in this country away from sick care to health care. Our goal in this bill with this provision is to change America into a wellness society, where it is easier to be healthy and harder to be unhealthy--just the opposite of what it is today. It is easy to be unhealthy in America today. It is hard to be healthy. We are going to change that around, and we are going to start with this bill.

One of the most important parts of this bill is the massive change we are going to make in prevention and wellness.

I note the presence on the floor of my distinguished colleague from North Dakota. I yield the floor.

Mr. President, I rise to speak for a few minutes about the health care legislation that has now been proposed by the majority leader and that we will be hopefully proceeding to for serious discussion, deliberation, and opportunity for amendment. Let me talk first about where we are today without health care legislation.

What are the circumstances faced by the average American family without enactment of health care legislation? The cost of medical care is rising. In fact, it is unaffordable for many individuals and businesses. In addition, there are 46 million who are uninsured in the country. That number continues to grow. I have been in the Senate and continued to watch that number grow for the last decade at least. Those most in need of health insurance often are denied coverage. Many others worry about whether they are one diagnosis away from financial ruin because of their lack of adequate coverage and their lack of ability to afford adequate coverage.

We are working in the Senate to craft a national health reform proposal that would remedy the situation and would do so by reducing the growth in the cost of health care. Let me be clear. We are not saying the cost of health care is going down substantially. We are talking about the growth in the cost of health care. That is what we are trying to moderate as part of this legislation.

We are also providing insurance to everyone in the country, regardless of

their health status and medical condition. This health reform proposal is designed to lower health care costs, lower than what they otherwise will be in the future. This health reform legislation caps what insurance companies can force patients to pay in their out-of-pocket expenses and in their deductibles. The legislation would let small businesses and individuals join purchasing pools and give them the lower costs that benefit larger groups today. I have heard from hundreds of small business owners in my State over the years who have complained that the cost of health care to them and their employees is so much higher than the cost of health care to large employers and their employees. We would solve that. We would create a system that helps to prevent illness and disease instead of just treating it when it is too late and when the cost is excessive.

This health reform proposal will reduce health care fraud and waste and abuse and overpayment to insurance companies. It is estimated by most experts to be in the range of $60 billion per year under the current health care delivery system. This legislation would eliminate most of the cost of uncompensated care. This is a substantial part of the premium people with health insurance are required to pay. They are not only paying for their own health care when they pay their premium, they are paying for the uncompensated care that hospitals, physicians, and others are providing to people who don't have insurance. That is the 46 million uninsured figure I mentioned before.

This legislation reduces the growth in the cost of public programs such as Medicare and Medicaid and helps to rein in the Federal deficit. We have the unusual circumstance that many of the individuals who opposed the establishment of Medicare and claimed it was socialized medicine are now resisting any effort to put it on a sounder financial footing and doing so purportedly in the name of defending the beneficiaries of Medicare. We need to speak the truth to the American people and say: Medicare and Medicaid are going to continue. There are going to have to be reductions in the growth of those programs in the future, the growth of the cost of those programs, and some of those changes are incorporated in this legislation. That is a good thing for Medicare beneficiaries. That is a good thing for people who are going to be dependent upon Medicare in the future. They will know Medicare is there. They will know Medicare is solvent and will benefit accordingly.

Health reform will also ensure all Americans have access to quality and affordable insurance. We prevent insurance companies from the current practices in which they are engaged. One of the worst of those practices is the practice of denying health coverage for preexisting medical conditions. If one has a preexisting medical condition and is able to buy a policy, perhaps, the policy in its own language will exclude them from getting medical treatment that might result from that preexisting medical condition. This legislation would end that. It would end the discrimination of charges that currently exist where the charge for health care is based on one's health status or gender.

During the course of this year and the last few years, while we have been studying the health care delivery system, I have come to a new understanding of what the word ``underwriting'' means. I used to think I knew what the word ``underwriting'' meant in insurance. What I have found it means is the screening out of people who might actually need the insurance that is being sold. So much of the effort of the health insurance industry today is not focused on assisting the patient or the policyholder; it is focused on screening out those individuals who might, in fact, wind up sick and might need health care. We try to end that in this legislation, and we do so effectively.

The legislation provides tax credits to middle-class families to make sure they can afford quality coverage. There are many middle-class families in my State who, frankly, cannot afford adequate and quality coverage for the parents and the children.

This legislation strengthens employer-based health care by offering small businesses a tax credit so that employers can offer competitive, affordable rates to their employees, if they choose to do so.

It creates incentives that reward doctors for healthy outcomes, not only for more and more procedures. We have the unfortunate circumstance today, for which this Congress and this administration and previous Congresses and previous administrations are responsible, where we have set up a system of payment, under Medicare in particular, where the amount the health care provider receives depends on how many procedures they perform, not on whether the patient gets better, not on whether they have done the right thing to assist that patient. We are trying to begin changing that with this legislation. This will result in better health care for all Americans.

Health reform is also designed to improve the choices people have when they go out to obtain coverage or to obtain health care itself. Most Americans get their insurance through an employer. Many are satisfied with the plans they currently have. They are satisfied with the physician or the doctor they currently have. It is clear in the legislation we are considering that this legislation does not require them to change that. This legislation says they can keep that policy. They can renew that policy. They can add family members to that policy if they choose to do so. But this health reform also provides security that ensures that families always will have guaranteed choices of quality, affordable health care. That is even when a person loses their job, when a person switches jobs, when a person gets sick, or a person decides to move from one community to another. This legislation will ensure that they have access to health care even in those circumstances.

It creates a health insurance exchange. This exchange would be a place where families and businesses could easily compare insurance plans and prices and make a judgment based on that comparison. This puts families, rather than insurance companies or government bureaucrats, in charge of their own health care. It helps people to decide which quality, affordable insurance option is right for them and for their family.

It keeps government and insurance bureaucrats, because there are bureaucrats working for insurance companies just as there are bureaucrats working for the government, both from coming between each individual and his or her doctor by simplifying insurance paperwork, by cutting out the pages of fine print, by eliminating all of the ``gotcha'' clauses people discover once they get sick. They find out they were not covered for whatever it is that now afflicts them.

By promoting computerized medical records, this legislation will dramatically improve efficiency in our health care system and, through that effort, also reduce cost.

Let me talk a little bit about the impact of this legislation on my State. I represent New Mexico. Frankly, this legislation is critically important to my State. This chart is a depiction of what is projected by the experts about the cost of health care in New Mexico. Without health care reform, my State is expected to experience the largest increase in health insurance premiums of any State in the Union. For example, the average employer-sponsored insurance premium for a family in New Mexico in the year 2000 was $6,000. By 2006, that had almost doubled to $11,000 for a family of four. By 2016, the expected increase goes to an astonishing $28,000.

In addition, this third chart highlights the health insurance premiums and the percentage those premiums represent of the income of the average New Mexico family. It is higher in my State, unfortunately, than in any other State in the Union. Today, 31 percent of a family's income is going to pay for health care. That is for the folks who have coverage today in New Mexico. That is expected to grow to an astounding 56 percent. Over 56 percent of a family's income is expected to be consumed just paying premiums for health care by 2016. That is totally unsustainable and unaffordable.

The health reform proposal that has been developed by the majority leader, based on the work of the Finance and HELP Committees, intends to slow the growth of health care costs around the Nation. The nonpartisan Congressional

Budget Office forecasts that the legislation would not add to the Federal deficit. In fact, it would reduce the deficit by $130 billion by 2019 and by more than $400 billion by 2029.

Most experts believe these reductions also will drive down the cost in the private health insurance market. Thus this legislation is critically important to my State because it will help to curb increases in health care costs for all New Mexicans.

Let me show you a fourth chart. This one is a chart based on--I guess this is data from the Census Bureau. It is a chart that was developed by the Commonwealth Fund. It is the percent of adults ages 18 to 64 who are uninsured by State. It has two maps shown on it. The first is for 1999 through 2000 and the second is 2007 through 2008.

You can see what has happened just in that relatively short period. In 1999 to 2000, there were two States that had more than 23 percent of its population uninsured, and those two States were Texas and New Mexico. The only State in the Union that has a higher uninsured rate than we do in New Mexico is Texas. That was the case then, in 1999 through 2000. It is still the case today, I would point out.

But what you can see from this map on the right of the chart for 2007 to 2008 is that many other States--particularly the States shown in dark blue across the South and California--many other States have joined the ranks of States that have over 23 percent of their population uninsured. Their aged 18-to-64 population was uninsured. This is a very serious problem.

I think my State has the lowest rate of employer-sponsored insurance in the Nation. We also have the highest rate of uninsured among employed individuals in the Nation.

Let me show you this next chart, this fifth chart I have in the Chamber. This is a pie chart that shows what the current status of folks in New Mexico is. I know it is difficult to read from a distance, but let me explain what it is.

We generally think of most people having private health insurance coverage. In New Mexico, 38 percent of our population has private health insurance coverage. So it is not a majority; it is 38 percent. We have 14 percent who are covered by Medicare. We have 22 percent who are covered by Medicaid and the Children's Health Insurance Program. We have 4 percent who are undocumented immigrants in our State, estimated at about 80,000 individuals. They do not have coverage today, and they will not have coverage once this legislation becomes law, if we are able to pass this legislation and the President is able to sign it.

Then this large red area shown down here at the bottom of the chart is 22 percent, and that represents individuals who have no coverage, excluding undocumented immigrants. So we have the undocumented immigrants, at 4 percent. Then we have 22 percent without coverage. These are folks who are here legally. Most of them are citizens. They do not have coverage. This gets back to the point I was making before about people's premiums today are covering not only the cost of their own health care needs, but they are covering the cost of the uncompensated care that is provided to this large red wedge of people shown down here on the chart. So it is a serious problem that needs attention.

New Mexico will benefit from this legislation in very important ways. The legislation will provide new Federal tax credits for private insurance, and it will also expand the Medicaid Program for individuals with incomes of up to 133 percent of poverty.

This is a very important provision for my State: It is projected that insurance market reform and Federal tax credits may reduce the cost of coverage in the individual/private market for the average family in my State by as much as 40 percent. So this last chart tries to take the previous information and say what would likely occur by 2019--10 years from now--if, in fact, we are able to enact this legislation.

You can see what the two biggest changes in the legislation are. The green wedge in the pie chart shows that we will have more people covered by Medicaid and CHIP. We would have 29 percent rather than the 22 percent we had before. It shows we will have many more people covered by private insurance. I believe for the first time in the history of our State, we will have over 50 percent of our population-- exactly 53 percent is what is estimated--who will be covered by private insurance and have an insurance policy they can depend upon.

So this would still leave undocumented immigrants--which is still estimated to be 4 percent of the population--without any guaranteed source of coverage. But we would have about 124,000 New Mexicans newly eligible for Medicaid coverage, and covered by Medicaid, we would hope. We would have an additional 238,000 New Mexicans who would be eligible for private coverage through the exchange or from their employers if their employers chose to provide that coverage.

We will have a lot of opportunity over the next few weeks to debate particular parts of this legislation. I look forward to that debate. I think the more the American people understand what is in this legislation, the more wholeheartedly they will support us moving ahead and enacting this legislation.

This debate has been a long time in coming. In the 27 years I have been in the Senate, we have not gotten to this point previously, where we were beginning a serious debate that might actually result in the passage of legislation, major comprehensive reform legislation. But I think we are to that point.

This is legislation that is currently available for anyone to review on the Internet, and I encourage people to do that. I encourage people to study the issue and follow the debate. As I say, the more people do study the issue and follow the debate, the more people will conclude this is worth doing, this is important to do.

So I very much urge my colleagues to rally around this effort. I hope, frankly, we will get some Republican support for this legislation. I think it is very unfortunate we are going into this debate with reports that all Republicans are agreeing to oppose health care reform. That is not the way to move our country forward. If there are amendments they would like to offer, obviously, they will have every opportunity to offer those, and some of them may prevail.

That certainly was the case in the Finance Committee when we marked up the legislation. That certainly was the case in the HELP Committee when we marked up the legislation. Amendments were offered from Republican members, and some were adopted. But to just say no, to just say: We are opposed to reform, is not a good option. I think the American people deserve better than that. I hope we will have a serious, substantive discussion about what the elements of health care reform should be.

I compliment the majority leader for putting together a very credible proposal that will move this country very far toward meeting the health care needs of all Americans. I hope by the end of this year we are able to enact that legislation or pass it through the Senate and go to conference with the House of Representatives.

Mr. President, I see my colleague is in the Chamber to speak on this issue, and I will yield the floor at this time.

If I could join this colloquy with my colleagues from Wyoming--what a great State to have two such exceptional Senators. First off, I want to make this point: Obviously, a lot of folks are pointing at this bill which I have right here--the Senator from Wyoming has one, and the other Senator from Wyoming has one--because it is real. Up until now most of the debate that has been occurring around here has been media. A lot of it has been theater. Some of it has been good theater, I hope, but it has been theater to a large degree.

Now we are dealing with something that is extremely real. Every page of this 2,074-page bill will have an impact on Americans. Every page of this bill will make a decision and direct a policy that will affect the health care of every American everywhere.

It is an extraordinarily intrusive and expensive bill. The Senators from Wyoming have been alluding to this, but it really is historic. The colleagues on the other side say this is a historic bill. It is historic. Never in my experience, and I don't think in any experience, has the Congress taken up a bill which is essentially going to restructure and fundamentally change the way that 16 to 20 percent of the national economy is going to be affected in such an immediate and intrusive way.

Essentially, the Federal Government will affect every decision that has to do

with health care as a result of this legislation, every decision that has to do with health care.

The cost this is going to create in the area of increasing the size of the government is astronomical. We have heard this number, that this is a $890 billion bill. That is pretty big. I suspect that would run the State of Wyoming for a few years, maybe a century. I think the State of New Hampshire would probably run for pretty close to a century--in fact, more than a century, to be honest with you. I don't think our budget is $8 billion yet. So that is a lot of money, $800 billion plus. But that is not the real number. That is a phony number. That is a bait-and-switch number.

That number is arrived at by claiming, over a 10-year period, that the programs that are initiated in this bill--which is a massive new entitlement--will not start until the fourth and fifth year. In fact, the House bill was at least a little more honest than the Senate bill. It started in the fourth year. The Senate bill starts in the fifth year with most of the spending. But the taxes which the Senator from Wyoming, the senior Senator from Wyoming was just talking about, and the fees and the reductions in Medicare, they start pretty much in the first year.

So they have taken 10 years of taxes, fees, and cuts in Medicare, and they have matched them against 4 or 5 years of actual spending and claimed that they are in budget balance and that the bill only costs $890 billion--only.

In fact, CBO has scored this over the real period, when all the programs are in place. Over that period, over that 10-year window when all the programs are functioning that are created under this bill--all of them being Federal programs, brandnew entitlements, extraordinarily expensive initiatives--when that occurs, this bill costs, by CBO's estimate, $2.5 trillion. In order to pay for that we would have to cut Medicare by over $1 trillion. In order to pay for that we would have to raise taxes, fees, by over $1.5 trillion. This is a massive increase in the size of government, a massive increase in tax burden, a massive effect on Medicare.

The Senator from Wyoming mentioned there are a few gimmicks in here on top of the huge gimmick, that it is a bait-and-switch, that this is a $800 billion bill when in fact it is a $2.5 trillion bill. There are a lot of other games in here that deal with budgeting. I found one of the more entertaining ones: the fact they take credit in this bill for creating a new program, the CLASS Act, a massive new program, a long- term care program. They take credit in this bill as that being a budget surplus item. How do they figure that out? Because on a long-term care program, basically people in their twenties, their thirties, their forties, even into their fifties, pay into it. It is like buying insurance under this plan, so that money comes into the Federal Treasury.

What they do not account for is when those folks go into their long- term care facility and the money goes out, the money goes out at an incredibly fast rate, and the program balloons radically in its costs. They do not account for that. They just account for the years when people are paying in, and they claim that as surplus money they apply to try to reduce the cost of the bill. So they spend the money.

This is classic. First, they take in the money and claim it as an adjustment against the debt they are running up, and then they spend it so it will not even be available to pay for the program they claim they are going to fund with it. It is just inconceivable.

Bernie Madoff is in jail. Whoever thought up this program and scored it in this bill, Bernie Madoff would be proud of that person. He would say: My type of guy. That is the way you do accounting--fake it.

It is unbelievable. There are a whole series of these types of games in here. The States are going to be taken to the cleaners by this bill. The allegation that we are going to expand Medicaid by 20 to 30 million people, and the States are not going to end up paying a huge bill as a result of that? Absurd on its face. It is absolutely absurd on its face.

More importantly, when we expand Medicaid by 20 or 30 million people, the doctor will tell you, back here, the reason Medicaid is in such dire straits is because doctors will not see Medicaid patients. Why? Because they are reimbursed at 60 percent of the costs. Who pays the other 40 percent, by the way, for the present Medicaid recipients? Who pays the other 40 percent? I will tell you who pays. Mary and Joe Jones, who are working down at the local restaurant who have health insurance, they pay it with their premium. Bob and Marie Black, who are working over at the local software company, they pay it with their health care premium. The 40 percent of Medicaid that is not paid for by the government is paid for by people who are in private insurance. Their insurance premiums go up because they are subsidizing Medicaid reimbursements because the hospitals have to get paid for the cost, and they are only getting 60 percent of it from the government and the other 40 percent is being picked up by the private sector.

When we expand Medicaid by another 20 or 30 million people, we are inevitably going to drive up the costs of private insurance again. So the private insurance policies go up. What does that do? It does what this bill is basically intended to do: it will force employers to drop private insurance and move people over on to the public plan. That, when you get down to it, is what this is all about. This is an exercise in having the Federal Government get control over all health care. It is being done in an incremental way. They are setting up a scenario that will not be immediately apparent to people. But as we move through the years it will become apparent because what will happen is the costs of private health care will go up so much that private employers will start to drop their health care. They will take the penalty, which is not that high in this bill compared to what they have to pay in health care costs, and move their people, and say: Sorry, I am not going to give health care anymore--or never did--and go get this government plan.

Then down the road Congress will change this government plan a little bit, and they will start to put price controls in, just like they want to do in Medicaid. Basically, that will mean people will get fewer products because as you put price controls in you will have less innovation, fewer drugs. Fewer devices will be developed because people will not be getting a return on their investments because these will be price-controlled events.

You will find delays because that is what happens when you move to a government program that controls costs. The government can only control cost by controlling price. That creates delays in access which is what happens in England and Canada. So the quality of the health care system goes down.

I ask my colleague from Wyoming, who is uniquely qualified to comment on this because he is a doctor and he has experienced the problems of dealing with Medicaid, is this not a reasonably accurate reflection of what will happen if we move another 20 or 30 million people into the Medicaid Program? Doesn't that mean that private insurance policies have to go up, fewer doctors will see fewer people, and inevitably we will end up with a cost shift which forces private insurers to drop insurance?

If I may ask a question on that point, this is an important point. As a practicing physician, if all your patients had been Medicaid, would you have been able to pay your bills?

If I might follow up, doesn't that inevitably mean that the people who are paying more are in the private sector, which means premiums for people in the private sector go up, which means fewer people are willing to give that type of coverage because the cost is too high for the business to cover; right?

I thank the Senator from Wyoming. He has a unique perspective which we should listen to, as a practicing physician for how many years?

That is impressive. He understands this whole issue and the point on cost. It is very hard to conceptualize that this is a $2.5 trillion bill when honestly scored. When honestly scored, it is a $2.5 trillion bill.

This page right here, page No. 1, cost the American people $2 billion. You could pick almost any page in this bill. And I don't think they are worth $2 billion a page. This page here, what does that say? I don't know. I am just picking this out: Transfer to the Secretary of Treasury a list of individuals who are issued a certification under subparagraph (h), including the name and taxpayer identification number for each individual, the name and taxpayer identification number of each individual who was an employee of an employer but who was determined to be eligible for the premium tax credit under section 36(b) of the Internal Revenue Code of 1986 because, A, the employer did not provide essential coverage, and B, the employer provided such minimum essential coverage, but it was determined under section--and on it goes--section 36 (b)(c)(2)(c).

I don't understand what that said. We now will have about 72 hours to figure it out. But I know this much: When a bill costs $2 billion a page and when it includes language such as that, it is something we should spend some time on. This bill is being rushed. It should not be rushed. This vote that will occur tomorrow at 8 o'clock at night, after having this size of a bill on our desks for less than 2, 3 days, is very serious. We are firing real bullets here. This is no longer theater. It is no longer political media. This is the passage of a piece of legislation, the potential passage of a piece of legislation. Tomorrow's vote is a critical vote because it basically will mean we are on the road to passage. In fact, 97 percent of the bills that come to the floor of the Senate under a motion to proceed pass.

So this piece of legislation is serious. It is real bullets at $2 billion a page. Tomorrow's vote is something we need to look at as a vote that is not some sort of a procedural vote. It is a substantive vote on whether we are going to fundamentally change the way health care is delivered, cause the size of this government to grow by trillions and trillions of dollars, and put the Federal Government virtually into every decision that has anything to do with health care. With the way you choose a doctor, the way you get your insurance, with the type of procedures you get, with the type of drugs you can obtain-- the Federal Government will be involved. How much it costs, the Federal Government will be involved. And with the type of debt that will be passed on to our children. This bill will play a major role.

Remember something about the Federal Government: Once you give the Federal Government power, you don't get it back. This bill is all about moving power here to Washington. That is what this legislation is about, about centralizing the decision process, the national decision process on health care. In the end, the goal, as openly stated by some of my colleagues on the other side of the aisle--and I appreciate the fact that they are forthright--is to

have a single-payer system where the government essentially runs health care top to bottom, much as it does in Canada and England. I believe that fundamentally undermines quality and is fundamentally unaffordable. It passes on debt to our kids which we obviously don't want. In the process, it will take Medicare, which is already in serious trouble--there is already a $55 trillion unfunded liability in Medicare--it will take Medicare's problems and aggravate them dramatically. To the extent savings are taken out of Medicare and used to create this new entitlement, which has nothing to do with Medicare or Medicare recipients but is going to be funded by Medicare both on the tax side with the HI tax in here and in the cuts in Medicare benefits with the elimination basically of Medicare Advantage, all of that is Medicare money that should be going, if you are going to do those things, to making Medicare more solvent for seniors, not to creating a new entitlement.

I see the Senator from North Carolina wants to jump in here.

Fully phased in, it is a trillion dollars.

The Senator has made a very good point, which is how you do health care correctly. You do not create a massive new Federal entitlement. You do not spend $2.5 trillion we do not have. There are a couple things you could do, though, on a step-by-step basis.

One of them--and I would be interested to know if the Senator understands why it is not in here--one of them is to correct lawsuit abuse. It is estimated $250 billion a year of medical expenditure is defensive medicine which doctors order and hospitals undertake simply to avoid the potential of a lawsuit being filed. CBO estimates it would be a $50 billion savings if we would adopt the proposals they use in Texas, California. That is one approach.

Another approach would be to allow employers to pay employees more who live healthy lifestyles, such as employees who stop smoking or employees who get the tests they need--whether it is mammograms or colonoscopies--when they should have them or employers who live healthy lifestyles and lose weight. Under the bill that is not allowed, other than what present law is, which is very restrictive. That would save a lot of money, by the way.

The first proposal, as I understand, was opposed by the trial lawyers. Do you think that is why it is not in this bill--saving $54 billion on abusive lawsuits?

The second proposal--allowing employers to pay a differential and pay employees who are living a healthy lifestyle more--is opposed by the big labor unions here in Washington. Do you think that is why it is not in this bill?

I wonder whether maybe the Senator from North Carolina has some thoughts on those two approaches as to whether they would help the health care system in this country, and why they did not find their way into a 2,000-page bill, since we seem to have a lot of room in this bill for things.

That is because we would have to change something called

It is a technical term, but it basically allows companies to pay an employee who lives a healthy lifestyle more than other employees, and that is opposed, as I understand it. It was originally in one draft, and it got dropped somewhere.

If I could jump in at this point.

I think the Senator has touched on something that is important; that is, when you start putting these major fees on things such as medical devices and drugs, you reduce the willingness of people to invest in creating the next device, and not only do you end up with a device being priced out of the market or maybe not being produced, but----

Then I will yield the floor.

Mr. President, I ask unanimous consent we be allowed to speak for an additional minute each, so we may wrap up our time.

My point is, this bill fundamentally undermines innovation, and innovation has been at the essence of what has made American medicine better than the rest of the medicine in the world. We are the most innovative country in the world in the areas of drugs and medical devices and procedures. I think this bill undermines that.

Mr. President, I thank both my colleagues from Tennessee and Georgia.

I want to talk just for a minute about what Republicans are for. We have been criticized by the folks on the other side of the aisle for being just against what they are for, and that is not at all true. There are actually four other plans that were filed in both the HELP Committee and the Finance Committee, three of which were strictly Republican plans, one was a bipartisan plan, that never saw the light of day, simply because the folks on the other side of the aisle had their minds made up that they were going to have their plan with a government option, and they were going to do whatever they could to move us toward universal health care coverage.

I want to say to those folks on the other side of the aisle who have stood up and said on the floor of this Senate: Yes, by putting a government option in place, our intention is for the government to take over health care--some of them have been very straightforward about that, and they have been honest. There have been others who have been not so honest about that. But that truly is the reason there is a government option in the plan we have up for a vote tomorrow night.

But what are Republicans for? First of all, everybody in this body is in agreement that we want to drive down the cost of health care and we want to drive down the cost of insurance, and those are integrally linked. If you drive down the cost of health delivery, then you will drive down the cost of health insurance.

There are a number of ways we can agree today to enact legislation that will help drive down the cost of health care. What are those things?

Preventive health care. Well, there is some mention of preventive health care in Senator Reid's bill somewhere in these 2,074 pages. There is the mention of preventive health care, but there is not the incentive in place to encourage people to move toward preventive health care as was done in the private sector with Safeway, a grocery store chain where the CEO has visited both Republicans and Democrats and talked about the way Safeway was successful in doing that.

We all want to make sure those who do not have insurance today are covered. We want to cover preexisting conditions. We want to make sure we put competition into the insurance market by allowing policies to be sold across State lines. All of those things will work in concert to drive down the cost of delivery, as well as the cost of insurance policies per se.

There is another measure that will significantly improve the cost of delivery; that is, putting in some measure of tort reform. In this bill, with these 2,074 pages, that seeks to totally reform the health care industry in America today, there is not one mention of reforming the tort system in this country, the malpractice reform area. If you go to any doctor and you ask him what is the No. 1 issue on his mind when it comes to reducing the costs in his office, I bet in 99 percent of the cases--maybe 100 percent--they are going to tell you that tort reform must be implemented if we are ever going to hope to drive down the cost of the delivery of health insurance in this country.

Senator Graham and I have an amendment we will be talking about that is a tort reform measure that is a loser-pays style of tort reform. It does not take away the right from anybody who is injured. Anybody who is injured ought to have the right to have their day in court. But it does eliminate the potential for the extensive, frivolous lawsuits that our docs and our hospitals have to deal with every single day that drive up the cost of health care.

I want to talk, too, about one other measure we are for that has been talked about a lot today; that is, covering the uninsured. I think, without question, if you want to drive down the cost of delivery and the cost of health insurance, you need to cover those people in this country who need to be covered.

We have a little disagreement with folks on the other side of the aisle as to the exact number they seek to cover with this 2,074-page bill. But there is one area where we do agree; that is, there are somewhere between 47 million and 50 million people in America today who are truly in that uninsured category whom we all, as a body of 100, would like to see have affordable insurance available to them.

Now, who are these uninsured? First of all, there are about 6 million people in this country today who are uninsured who are here illegally, and they are illegal, undocumented aliens.

Folks on the other side--and there is some question about this when you look at the language in this 2,074-page bill, whether they cover those illegal aliens, but let's assume we all agree they ought not to be covered. There are another 14 million people in America today who have health insurance available to them from the Federal Government in one form or another. Either they are Medicaid eligible or they are eligible for some form of SCHIP, the State Children's Health Insurance Program. In Georgia, it is called PeachCare. For whatever reason, these 14 million people have not taken the initiative to go out and sign up, for example, in Georgia, at the Department of Family and Children Services. I do not know what it is in Tennessee, I say to Senator Alexander, but there is a comparable office in all 50 States for that to be done. What do these 2,074 pages seek to promote as to the 14 million people who have insurance available to them today to go in and take that insurance? Nothing. So these 14 million people are not even addressed.

Then there are another 15 million people to whom Senator Isakson just referred. They are people who are either those independent contractors or they are employees who work for employers who do not provide health insurance, but all of them are gainfully employed, and they have the ability to purchase health insurance. Some of these people are dealt with in this 2,074-page bill. Some of them are not because if you are an employer with 50 or fewer employees, then you are exempt, you would not be covered, still, as a part of that 15 million.

Then there are about another 12 million to 15 million whom I refer to as the hard-core uninsured. Those are the folks whom we really ought to try to reach, and those are the folks to whom the bulk of the $2.5 trillion this bill is going to cost during the 10 years when it becomes fully implemented seeks to reach.

I would simply say, if we are going to truly have a health reform bill, we need to start and take it step by step. If the folks on the other side of the aisle are serious about health care reform, we can get the appropriate committee chairmen together this afternoon, tomorrow, or whenever, and begin work on these issues I have just laid out about which there should be no disagreement. We could move forward with developing a true and meaningful health insurance reform package.

I want to come back in a minute and talk about Medicare taxes and the way Medicare is going to be dealt with here. But I would simply throw it back to the Senator from Tennessee, as well as to my colleague from Georgia, because they have both been involved in a very honorable way at the State level. Senator Alexander is a former Governor of Tennessee. Senator Isakson was an elected member of our State house, as well as our State senate.

I say to the Senators, you gentlemen have experience dealing with Medicaid, and you know what the taxation side of Medicaid does from a State level. I would like to ask for your thoughts on what this 2,074- page bill is going to do to Medicaid in this country as we know it today.

In addition to that, we are going to continue to tax young people who are in the workplace for additional Medicare taxes that are intended to be used by them in what is called the CLASS Act, which is another part of this monstrous bill, and chances are those people are never going to see those benefits. There is one tax after another in this bill that applies to Medicare.

One other aspect of Medicare that is of such critical importance here is that they have an $850 billion pricetag, according to the Democrats. According to the numbers and the figures of Senator Gregg, the ranking member of the Budget Committee, who came down here this morning and talked about it, that $850 billion is for the first 10 years. The taxes begin next year. The benefits don't begin until 2014. When you look at 2014 to 2025, the first 10 years of full implementation, the cost of this bill is actually $2.5 trillion, not $849 billion.

Why is it $2.5 trillion? Well, it is because the scope of government has broadened to such an extent that the expense of providing the services is going to be greater. We are going to have more people coming onto Medicare. We know now, as Senator Alexander said, according to the bipartisan Medicare Commission, we will be paying out more in Medicare benefits than we receive in Medicare taxes in the year 2017. There are only two ways to fix that: either raise taxes or decrease benefits. The majority that is in power in Congress today has a habit of not seeing a tax they don't love, so my guess is that is the direction in which they are going to want to go: Raise taxes on Medicare beneficiaries and those in the workplace again to ultimately pay for Medicare benefits down the road.

The other part of this I wish to address with respect to Medicare is the Senator from Florida got up as we were coming on the floor and talked about this so-called deficit reduction. What do they mean when they say we are going to have a $32 billion deficit reduction over 10 years? Well, here is how it works. The deficit reduction is brought about primarily by the addition of a program in this bill to Medicare, what is called the CLASS Act. The CLASS Act is a long-term policy of insurance to take care of long-term health care needs. Young people are going to be required--young people in the 20, 30, 40-year age bracket will pay into the so-called Medicare trust fund that will be used to pay benefits for long-term care for those individuals when they start reaching the age where they need long-term care. So CBO has said that because these folks are 20, 30, and 40 years old and they are going to be buying these policies, they are not going to be getting any benefits for another 20, 30, or 40 years. So we are going to take the position that all of those premiums, which go into the general fund, by coincidence, will go to reduce the deficit. But guess what is going to happen, even according to CBO, when all of these young people who have been paying into the CLASS Act start getting benefits. All of a sudden we are going to start seeing deficits in the outyears, and our children and our grandchildren are going to have an additional debt put on them because of the way this particular provision is scored--and it is being touted as a deficit-reducing provision right now--that truly is going to be a provision that adds to the deficit and the debt our children and grandchildren are going to have to pay.

I would ask the Senator from Kansas if he would yield for a question. The question is: The Senator from Kansas and I were elected to Congress in the same year. This is our 15th year, I believe, of serving. You have been over here longer than any of us have, and you were involved in State government as well.

Have you ever seen a Federal program that was projected to be at X number of dollars of expenditure which came in on time and on budget?

Do you think that when Senator Reid comes down here and says this bill is going to cost $849 billion over 10 years, that is a correct figure for a massive reform of health care?

I ask my colleague from Georgia, we talked about this, and he has had extensive experience at the State level with respect to Medicaid. Take our State--and I think we are representative of all 50 States. We have a Medicaid Program now that provides for coverage or eligibility at 100 percent of the poverty level. This bill takes that to 133 percent of the poverty level. Talk for a minute about the impact of going from 100 to 133 percent to cover some of those uninsured I referred to earlier. What is the impact on our State?

Whether it is paid by the Federal Government after that 3 years or by the State of Georgia, whose pocket will it come out of?

I don't think we can overstate what the Senator has said. Not only is the Federal Government looking at the largest deficit we have ever seen in the history of our country--just this past year, $1.3 trillion--but every State is having the same problem. That deficit is trickling down.

In Georgia, for example, we have one county that has run into these education reductions that Senator Alexander is talking about, which universities are facing. That one school system reduced the days the children are going to school from 5 to 4 days to save the cost of buses running and other bills, for heating and whatnot, for that extra day. That is not what we need to be doing as Americans. We need to figure out a way to struggle through this.

Instead of struggling through it, we are now in the toughest times we have ever seen, as Senator Brownback said, we are adding these huge taxes that will stifle the small business community on top of the debt that we have seen created in this country just in the past 12 months.

These are not people who are on the extreme right or extreme left who are bombarding us with phone calls, e-mails, and letters as all of us get on airplanes, as I did Monday. I had people come up as I walked through the airport, and as I was on the airplane, and when I got off the airplane, saying: Please stop this bill. Don't pass this foolish bill that you all are talking about up there now. It is amazing, the type of folks who will come up and say that.

I have two quick anecdotes I would like to read. One is a letter I got from a doctor. It reads:

Dear Senator:

I am a vascular surgeon in Rome, GA, with a patient

population that is 70 percent Medicare. I am deeply concerned

about the proposed Medicare cuts. After 8 years of college

and medical school, and 7 years of training, I have

accumulated a large debt in loans and interest. Plus there is

the huge administrative burden of a large Medicare population

in my practice. I don't know how I and other physicians are

going to be able to afford to continue to see Medicare

patients if these cuts go through. As it stands now, I am

paid only 23 cents on every dollar charged. I would

appreciate help in staving off these cuts.

The other one is an e-mail I got in the last few days about a good friend of Senator Isakson and mine, Bob Lovein, a funeral director in Nashville, GA, which is close to my hometown. It says this:

A lady walked into the funeral home and gave him a letter

from the VA. The letter stated that they (the VA) owed her

$307 on her husband's death benefits. Bob pulls her husband's

file and he had buried him 10 years ago . . . and we trust

the government to run health care?

That is how ridiculous it is in the minds of people in this country who are calling and writing our offices--certainly the offices of every one of the Members of this body--because they don't understand why we are mortgaging and sacrificing our children's future, or why, as Senator Brownback says, when the President goes to China to see their banker--China owns almost $1 trillion worth of our debt--the Chinese Premier asked the President about the health care bill because he is concerned about the way we are spending money here.

I can never remember any foreign leader ever asking the President of our country about anything to do with the financial condition, particularly a program like this, which would affect us.

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

Mr. President, I am very proud to be here with colleagues of mine who have today joined me on the floor. Senator Merkley from Oregon and Senator Mark Begich from Alaska are such strong, passionate voices for people in this health care debate, for what we need to do to stop the insurance abuses and to save lives and save money. I am so pleased they are both here with me. Let me take a moment before turning it over to them to talk about what this is really all about for us.

Right now, the bill in front of us basically saves lives and saves money. We save lives through making sure that the 47,000 people who lost their lives last year because they couldn't find affordable health insurance to be able to see a doctor--making sure we change that; by focusing on prevention, also, so people have early detection and people can find out earlier when they have cancer and get the treatments they need to save their lives. There are so many ways in which this bill in front of us literally will save lives.

We save money. We save money for individuals and small businesses that are currently having a difficult time finding affordable insurance. If you have your insurance through an employer, as do about 60 percent of the people in my State, and if you are a large employer, then you can get a better rate because you have a large group plan. If you are a small business, you don't get that same treatment today. If you are an individual, if you are, like many people today, operating out of your home as a businessperson, a single entrepreneur, or maybe you are creating that next great invention in your garage and you are trying to find health insurance as a single individual for yourself and your family, you can't do that right now in a very affordable way.

So we want to fill in the gaps in a system that has worked well for many people with employer insurance and certainly for people in Medicare and our veterans with the VA and our military personnel and others. But we have a little less than 20 percent of the public right now that is left out there without a way to get affordable insurance, so we want to bring down their costs. We want to bring down the costs for our bigger businesses as well.

We want to make sure we are stopping people from using emergency rooms inappropriately and raising the cost on everybody with insurance and instead give everyone the opportunity to see their own doctor, their family doctor, and make sure their children and their families get the care they deserve.

We know this also saves money for the Federal Government, for States, for our economy as a whole, and we know what the numbers are in terms of inaction, the fact that we need to bring down costs across the board.

This bill protects Medicare. We know we would not have the AARP endorsing the House plan and hopefully supporting ours as well--I know they are still looking through the specifics, but they certainly support health care reform, and we welcome their support. They want health care reform. They have said certain things that I think are very important that debunk what we have heard from the other side of the aisle.

We have heard over and over that health care reform will hurt Medicare. The AARP Web site has up on its site: Myth: Health care reform will hurt Medicare. And then it says--not from us but from the AARP, a champion for senior citizens in this country--Fact: None of the health care reform proposals being considered by Congress would cut Medicare benefits or increase your out-of-pocket costs for Medicare services. None of the proposals we have introduced as the Democratic majority, supported by President Obama, would do that.

Fact: Health care reform will lower prescription drug costs for people in the Medicare Part D coverage gap, or what has now been dubbed the ``doughnut hole,'' so that they can get the better, affordable drugs they need.

Fact: Rather than weaken Medicare, health care reform will strengthen the financial status of the Medicare Program--strengthen it for the future.

We know Medicare has been a great American success story, and we want to make sure it is on strong financial footing to go forward for all of us who are baby boomers and beyond, to our children. This comes from the AARP Web site. So we strengthen Medicare. We protect Medicare.

Then we focus like a laser on stopping insurance abuses. We have heard so many times, unfortunately, story after story about families who cannot find insurance because someone in the family has a preexisting condition of some kind--a child who has leukemia, someone who is a diabetic. Even for women, pregnancy has been used as a preexisting condition. We want to make sure all Americans have the opportunity to find affordable insurance. We want to make sure that if you have insurance you have paid for your whole life, you have paid the premiums, you feel confident that because you have health insurance, when somebody in the family gets sick, the companies can't drop you on a technicality.

So we have a number of areas in which we want to stop abuses and, frankly, strengthen the system. We want your children to be able to stay on your policy until age 26 if they need that. That is something I have often said that I wish had been in place a couple of years ago because I know what it is like to have a son or daughter come out of college and that first job doesn't have health insurance.

We want to make sure early retirees get the health care they need and are able to afford their health insurance with the Federal reinsurance plan, to help businesses keep costs down for people who--frankly, many have been forced to retire at age 55 or age 60 and don't yet qualify for Medicare.

So this is the bottom line: We are saving lives, we are saving money, we protect Medicare, and we stop insurance abuses.

I wish to focus for a moment on something else we are doing that is absolutely critical to me and, I know, to colleagues across the country, because this plan will also save jobs. Folks have said to us: Well, don't talk about health care; let's talk about jobs. Lowering the cost of health care is about jobs. It is about jobs. We lose jobs overseas to other countries that have lower health care costs than we do. We have seen plants--in fact, in Michigan--go across a river that you could swim across, the Detroit River, from Michigan into Canada, everything else being equal--a unionized labor force, environmental standards--everything else equal but one thing: the health care costs are less. So this is about jobs, and it is about keeping jobs in America.

We know our plan will allow big employers to save $9 billion over the next 10 years--$9 billion. What will they do with that? They will put that back in,

reinvesting in equipment, building other plants, hiring more people.

Health care reform is about jobs.

Small businesses are estimated to save 25 percent in their costs over the next 10 years with the tax credits we have in the bill--the ways we create the ability to buy through a large pool, to be able to lower costs, and with the tax cuts in the bill to small business. There are tax credits to help all the companies that don't have insurance to be able to find affordable insurance.

The bottom line is, it is estimated that if we do nothing, the costs to businesses will double, and we will lose 3.5 million jobs. We can turn this ship around and begin to bring down costs. It is estimated we can save 3.5 million jobs.

People in America understand we have to focus on jobs and the economy. They also know the one-two punch is that when you lose your job, you lose your health care. So in our bill, we specifically create policies that make sure that if you lose your job, you don't lose your health care.

We want businesses, large and small, to be able to redirect the spending on ballooning health care costs and premiums, to be able to redirect that on hiring people and doing what we know how to do best, which is making things in America and putting people to work.

This is about jobs. It is saving lives and saving money and saving jobs in this country. I will conclude by saying that what are we hearing from our colleagues on the other side is the same kind of tactics that were argued in the 1960s before Medicare. You can take some of the same arguments and lift them right from the pages of the Congressional Record and you would think it was today's debate, but it was actually back in 1964, 1965, with Medicare. We know the arguments they used then about destroying the economy, about costs going up, about people losing access to doctors, and about how this would hurt businesses--it didn't happen then. We know it will not happen now. But what we are hearing is: Just wait, wait, wait, wait--that is all we heard in the Finance Committee. Don't do it now. What is the rush?

Well, if you are not getting those premium increases in the mail, maybe you don't feel the rush. If you are not losing your job and health care, maybe you don't feel the rush. But we have been talking about this for 100 years. We are tired of waiting. The American people are tired of waiting. They are saying business as usual for insurance companies: Let the insurance companies decide whether we are going to have maternity care covered under basic insurance. That is not necessary. It is an option. Let them decide whether we are going to focus on prenatal care.

We are 29th in the world in the number of babies who live through the first year of life--below Third World countries. Right now, 70 percent of the insurance companies in the individual market don't offer maternity care as basic health care. They say let the insurance companies decide. Let them be the ones between you and your doctor. When a doctor says what he wants to do when you are sick, what is the first call they make? To the insurance company. They say that is OK, let the insurance companies be the ones deciding what you are going to pay or get, whether you are going to be able to find coverage. Let them stand between you and your doctor. We say: No, we have had enough of that.

Finally, they say higher costs for middle-class families and small businesses are OK. Higher costs are OK because they are willing to allow this craziness to continue. Mr. President, we are not.

Let me emphasize, again, the bottom line: This is about saving lives, about saving money, and it is about protecting Medicare and stopping insurance abuses. We are committed to doing those things, getting through all the misinformation. All those who make so much money off the current system are just flailing and saying anything right now to try to stop us from getting control of the system and bringing costs down and making health care available. We are committed to getting this done for the American people.

I yield the floor.

Mr. President, I wish to take a few moments and continue this discussion and then turn it over to the distinguished Senator from New Mexico, Mr. Udall. We are so pleased to have him. We served together in the House. We are pleased to have him as a colleague in the Senate. They are a terrific team of people who are so smart, who care so much and have such great experience. Our previous speaker, coming from Oregon as the leader in the State legislature, and Senator Begich, as a leader, as a mayor--we bring a wealth of experience of people who have been serving, problem-solving, trying to make government work, make the right decisions at various levels of government. It is wonderful to be working with them today.

I wish to take a moment because I understand that the Republican leadership, our colleagues, are currently holding a press conference talking about what we are doing is somehow rationing care. This is the same argument, by the way, used back in the sixties with Medicare. Somehow seniors would not be able to get care, it would be rationed, which, of course, is the exact opposite of what happened.

Now people hold their breath if they retire early and don't have insurance, just waiting to turn 65 so they can get Medicare and they can see whatever doctor they want, not the one the insurance company says they can see but the doctor they believe they need to see, the specialist they believe they need to see.

We know that for too many people in this country, there is the ultimate in rationing. Over 45,000 people lost their lives last year because of the ultimate rationing. They couldn't find affordable health insurance. They couldn't see a doctor. They couldn't get the care they needed. Mr. President, 45,000 people in the greatest country in the world paid the ultimate price. Shame on us. We want to stop that. This legislation will head us in the direction to stop that, to say as a matter of principle in this country that it is not acceptable that any American would lose their life, any mom or dad would lose their child because they could not find affordable insurance in this great country.

We also know that every year we push as hard as we can to increase the amount of money going to the National Institutes of Health to gather information, to do research to save lives--to save lives through research, through information. In this legislation we want to make sure as the NIH is doing more research, as we are looking at better prescription drugs or new cures, that we are giving physicians and patients the very best information.

I am not scared of information. I want information for my family, for myself. I have been in a situation--I am sure that we all have--talking to

my physicians, where they said according to the latest data we now think a little bit differently about a particular procedure or a particular medicine. And they make a different recommendation. I want my doctor to have that information. That is not rationing. In fact, we specifically say in this bill, we specifically prohibit the Secretary of Health and Human Services from denying coverage of treatment solely based on research, solely based on information. But we certainly want the information.

I think it is kind of silly to even argue about whether we want medical research and information so our doctors have the very best information to be able to treat us. Right now, less than 1 percent of our health care spending goes to examining what treatments are most effective. We want to make sure the information is there for physicians. Physicians support that, by the way. This is something in the House bill, endorsed by the AMA, endorsed by medical professionals all across the country. We want our doctors to have more information to do a better job for us, not less.

We are hearing, over and over, scare tactics. We know we are going to continue to hear that until we get to the end and pass this bill. But none of the groups--doctors, nurses, family groups, consumer groups, business groups--none of those who currently support this legislation would be doing so if they thought it was in fact doing the things the other side is claiming it is doing, and certainly not if it was rationing care. The ultimate rationing right now occurs when people arbitrarily get dropped because the insurance company doesn't want to pay the bill; when people cannot get the coverage they need because of a preexisting condition; or when they lose their life because they can't find affordable insurance. Our legislation is about saving lives and saving money.

I wish now to turn the floor to my colleague from New Mexico.

Mr. President, I appreciate the opportunity to be here with my colleagues from Arizona, Mississippi, and Florida.

When the people of the United States talk about health care reform, they are seeking some way to control the punishing and skyrocketing increases, year after year, in health care insurance costs and medical costs and better access and quality of health care. Yet when this 2,074-page bill, which was crafted in secret for the last 2 or 3 weeks, was finally revealed, that is hardly what we got. In fact, the reality is that this bill will drive up the cost of health care insurance and medical care in this country. It will increase taxes by hundreds of billions of dollars. It will cut Medicare by hundreds of billions of dollars. It will grow the Federal Government by $2.4 trillion of new spending over a 10-year period. It will push the needy uninsured not into subsidized health care insurance but into a failing entitlement program, Medicaid. It will impose a damaging unfunded mandate on States that are already strapped financially. It will leave millions of Americans uninsured, while probably creating the most enormous and massive government extension of Federal control over our economy that we have seen in our country, starting with creation of a new federally owned and managed insurance company.

As the Senator from Arizona indicated, today we are here to focus on the Medicare cut aspect of this legislation. The Senate bill contains something in the neighborhood of $500 billion of cuts in Medicare. The first one I want to focus on is the one the Senator from Arizona already identified; that is, the Medicare Advantage cuts.

The Senate bill contains $118 billion in cuts to the Medicare Advantage Program. Let me talk about that program for a minute. Currently, there are nearly 11 million seniors, as has been indicated, enrolled in Medicare Advantage. That represents about one out of four of all Medicare beneficiaries in the United States. In my State of Idaho, there are more than 60,000 Medicare Advantage beneficiaries, which is about 27 percent of the population in Idaho.

In addition, this is an extremely popular program. A 2007 study reported very high overall satisfaction with the Medicare Advantage Program. Eighty-four percent of the Medicare respondents said they were happy with their coverage and 75 percent would recommend Medicare Advantage to their friends or family members. Yet, despite this, there are massive cuts coming forward in the bill. Why would that be the case?

I don't think most Americans who are not on Medicare recognize the difference between Medicare generally and Medicare Advantage. Medicare Advantage was a modification of the traditional Medicare Program that, frankly, was put into place--I ask my colleague from Arizona to comment. Wasn't it put into place when the Republicans were in control of the Congress to try to help get market forces more engaged and involved in the administration of Medicare benefits?

If you look at the Federal entitlement program Medicare, the portion of Medicare that truly does have some private sector involvement, where private sector companies can come in and contract to provide the government's responsibilities under Medicare, it is the most popular of all Medicare programs, the one that was growing and letting the private sector deliver the benefits.

One of the aspects of the Medicare Advantage Program is that senior citizens on Medicare Advantage actually get additional benefits beyond those traditional Medicare benefits that those in the normal or standard Medicare Program get because the private sector options have been able to identify ways to enhance and create opportunities for greater and stronger benefits.

Yet those who don't want to have anything but a single-payer system, those who want to make sure the government-provided health care is provided only by the government, do not like the Medicare Advantage Program. So it is not surprising that we see this level of cuts in this program.

During the Finance Committee markup, CBO estimated that the value of extra benefits that Medicare Advantage plans provide will drop from $135 a month to $42 a month of extra benefits. The CBO Director, Mr. Elmendorf, confirmed this during the markup. I asked him:

So approximately half of the additional benefit would be

lost to those current Medicare Advantage policyholders.

His answer was:

For those who would be enrolled otherwise under current

law, yes.

In other words, compared to current law, if these cuts are put into place, about half of the benefits would be lost to these Medicare Advantage beneficiaries.

We now have more detail on that. I am sorry we don't have a bigger chart. We will have one in the future. If you can see the United States here, the States in the deep red are those that have cuts in excess of 50 percent to their Medicare Advantage beneficiaries; those in the lighter red are between 25 and 50 percent. In the white, there are only five States; they are the ones that don't have a negative impact. So 45 of the 50 States will see significant reductions in the Medicare Advantage benefits that are provided to their constituencies. You just have to look at the map to see it is a large percentage of those 45 States that are getting cuts in excess of 50 percent of their benefits.

Yes.

The Senator is right. The way I look at it is that it is the extras. Some say Medicare benefits aren't being cut by these proposals, but that is a real stretch. When you look at Medicare Advantage, it is an outright misrepresentation. The benefits are vision benefits, dental benefits, and the kinds of preventive medicine, such as the mammograms, the PSA tests, and other types of things we have found that help you to dramatically increase your health, if you pursue these kinds of preventive medicine options. They are the ones that will be deprived through these benefits.

That is absolutely true. Taking a couple of other States, California is 68 percent; Arkansas, 40 percent; New York, 69 percent; New Mexico, 65 percent. The list goes on. The point here is this: The CBO Director made it clear that these will be benefits Medicare Advantage holders will be losing.

I want to move on to some of the other reductions in Medicare. The argument being made by the proponents of this bill is that we can cut $500 billion out of Medicaid and not impact anybody's benefits or the quality of the medical care they are receiving. That is not true. Where are the other cuts, non-Medicare Advantage cuts, coming from? They come from home health agencies, hospice, skilled nursing facilities, hospitals that provide care to seniors, and other Medicare providers in what is called the market basket.

You might say we can just continue to cut the compensation or the allocation of return for procedures and health care provided in these medical providers' services and not have any impact. The reality is far from that. What will happen is this. I will give a couple of specific examples. In general, what happens is, when a home health agency or a skilled nursing facility or a hospital receives these massive reductions of over $100 billion worth of cuts in these areas, they have to adjust somehow. Let me give you some examples. The adjustment is this: In some cases, providers simply stop taking Medicare patients because they can no longer make a profit. In that case, the Medicare population loses access because they have fewer providers from which to choose. In other cases, they reduce services or reduce employees. Again, both the quality and the quantity of health care services to seniors is reduced.

Let me give some examples. A few weeks ago, I spoke to Gary Thietten of Idaho Home Health and Hospice about the impact of Medicare cuts to home health and hospice providers, which is his business. He described to me just how bad the fiscal situation has already become for home health, hospice, and other Medicare providers in Idaho.

Idaho has already lost nearly 30 percent of its home care providers. Let me repeat that. Already, it has lost nearly 30 percent of its home health care providers. They are going out of business because we are squeezing them down so tight. And that included Idaho's largest provider. The providers that are still in business are working under the same Medicare reimbursement levels they received in 2001--8 years ago. If the kinds of cuts contemplated by this legislation go into effect, on top of the current reimbursement issues, the situation will get worse.

Gary said that he compared this situation for home health and hospice providers to the farmers in Idaho. He said that most farmers don't grow just one crop. Similarly, home health agencies do more than just provide home health; they provide hospice and private-duty care along with medical supplies and equipment. All of this will get reduced.

Let me give another example. Robert Vande Merwe of the Idaho Health Care Association talked to me about the impact of these cuts on skilled nursing facilities.

Skilled nursing facilities, such as the hospice facilities, already face a budget challenge under recent CMS rules restricting their compensation for the services they provide. The cuts they have already received, not counting what will come at them in this bill a hundredfold more, have already caused a reduction in reimbursement in Idaho by over $4 million per year to skilled nursing facilities.

He pointed out to me that in the nursing home world, more than 70 percent of the expenses they have are labor, primarily nurses and nursing assistants. He said when payment cuts like these occur, they cannot go to their buildings and take bricks out of it. What they have to do is reduce their employment. That cuts employees. That cuts benefits and services to those who are there.

Let me make this clear. First of all, these cuts are going to reduce jobs and, secondly, they are going to directly tie to the quality and number of staff there to provide care for those in the Medicare system.

Mr. President, I appreciate that question, who are the providers. If this Medicare beneficiary is in a skilled nursing facility, the provider is the facility itself, which I said we already lost 30 percent of our facilities. It is the nurses and the nurse assistants who are there to assist them and care for them.

The bottom line is, you simply cannot cut hundreds of billions of dollars out of these services and expect to provide the same level of access and quality and available health care.

The same would be true if the care were being provided in a home setting, which a lot of the home care services are compensated by Medicare or in a hospital which is there to provide care in some of the most serious types of circumstances. Whatever it is, whether it is home hospice care, skilled nursing facility, a hospital or what have you, what we see is a reduction in the number of facilities and personnel available, and that is nothing other than rationing.

It is a different kind of rationing than will occur under some other parts of this bill where the government will actually get in the business of saying what kind of health care you can get and at what time in your life you can get it. But it is a kind of rationing that simply forces the availability of health care down so far that the system itself rations it out.

The Senator is absolutely correct. I will comment on that and then conclude and turn the floor over to my colleagues from Mississippi and Florida for their comments. That is exactly right. In fact, one of the most clear and obvious places in which

this legislation violates the President's pledge--that if you like what you have you can keep it--is in Medicare Advantage because one out of four Medicare beneficiaries in America will not be able to keep what they have and will see their benefits cut.

There are also other parts of this bill that impact people outside of Medicare in terms of the kind and quality and extent of health care insurance coverage they have and expect that will be impacted. It would impact beyond this. This is about as clear a case there is of violating that promise.

The Senator is correct. I will conclude with this. I think we have all seen folks are almost falling over themselves backing away from the news on the mammograms that came out. But it is a very clear example in a way a study can come out from a government source or otherwise to say we don't need to have this kind of health care in the United States, it is a cost saving. What do you think is the potential for this commission to say: We are charged with saving costs in these programs, and we are going to do that.

I suspect that the mammogram issue is one they would not do it on today because of the reaction to it. Somewhere this commission is going to save tens of billions of dollars, in addition to these kinds of cuts, by reducing services. Color it as you want, you cannot make this kind of reduction of health care services, personnel, and infrastructure without reducing the access to and the quality of care that Americans receive.

I will conclude by saying these issues face every State in America. We are going to see in this arena a dramatic reduction of the quality and content and quantity of health care that our Medicare beneficiaries today see because of these proposals, and they are being done not in order to make the Medicare system more solvent but to finance yet another major Federal entitlement program that will cost hundreds of billions of dollars. As a matter of fact, if you look at the true numbers, the cost will be over $2 trillion in a full 10-year period of time.

There is a lot more we could say, but I know my colleagues from Mississippi and Florida have some remarks they wish to make. I yield to them at this time.

The Senator is right. As a matter of fact, if I understand the

legislation correctly, it assumes the current projected cuts for physicians are going to happen. That is how it says it is not going to increase the deficit. You and I both know this Congress will not let that happen.

But even today, 29 percent of Medicare beneficiaries looking for a primary care doctor had a problem finding one because, both with regard to Medicaid and Medicare, because of the problems we have been discussing here, there are fewer and fewer providers who will take patients in those programs.

That is OK as long as it is taken from the Democratic time.

Mr. President, the Republican side should now have 60 minutes; correct?

That will extend until about 2:05.

Mr. President, the debate has begun. The debate is about reducing health care costs--the cost of premiums every American has or the cost to the government that every American has to be responsible for. The bill we have been presented goes in the opposite direction. It raises taxes. It means higher premiums. It cuts Medicare. It transfers major new costs to States which, in turn, will damage higher education and/or increase taxes or both.

Our purpose on the Republican side is to take this next hour, as we intend to take several hours, all the hours allocated to us today and tomorrow, and help the American people have a chance to read the bill section by section, to understand what it costs and to understand how it affects them.

In this next hour, the Senators from Georgia, Mr. Chambliss and Mr. Isakson, and the Senator from Kansas Mr. Brownback, will be focusing on tax increases. We will be referring specifically to page 348, title I, subtitle (f), part 2 of this 2,074-page bill, which has to do with the tax on employers. We believe a great many employers will look at this big bill, look at the tax on them, if they don't pay insurance, look at the new government program and say: It is going to be a lot easier for me to pay the fine and write a letter to the employees and say: Congratulations, I have written a check to the government. You are on the government plan.

Then we will go to page 2,040 of the bill, which is the new Medicare payroll tax. That is a tax on hiring. You heard that right, a tax on hiring in the middle of a 10-percent unemployment situation. How is that going to create any jobs? We don't think it will.

Then Senator Chambliss, especially, and Senator Isakson, because of his background as a small businessperson, will talk about what Republicans want to accomplish. If you are waiting for the Republican leader to roll in a wheelbarrow with a 2,074-page Republican version of health care reform, you will never see it. We don't believe in that. What we do believe in is identifying a goal--reducing the cost of your premium, reducing the cost to the government, and then going step by step toward that goal; for example, by reducing junk lawsuits, by allowing small businesses to pool their resources to purchase insurance, which we have offered but the Democrats will not allow to come forward, and by allowing people to purchase health insurance across State lines. Senator Chambliss and others of us will talk about this during the next hour.

That is the Republican plan, to do what most Americans want done, to reduce the cost of premiums, and to not increase premiums and taxes, or cut Medicare.

There is one hidden tax I wish to talk about because it is in the bill, and it is in the news. Most Americans may have seen that the University of California yesterday raised tuition 32 percent. There are, in our country, around 18 million students who are in higher education. What I wish to say to them is, if this bill passes, their tuition is going up. California's tuition is going up again. It is going up in Tennessee. It is going up in North Dakota, in Nebraska, in Georgia, everywhere there is a public college, university, or community college there are going to be new taxes or higher tuition or both.

In California right now, they are pointing fingers at each other about the 32-percent tuition increase. But they should be pointing the finger at us, Washington, DC, Congress, because it is we who have allowed the Medicaid Program, the largest government-run program we have in the country, to go year after year with increases of 7 or 8 percent. We require every State, if it opts in, to have a government- approved Medicaid Program. In our State, it is called TennCare. That Medicaid Program is helping bankrupt the States.

Here is a State of Tennessee headline: ``State looks at $1 billion in cuts.'' Part of that is from the recession. But part of that is because of the increased cost of Medicaid. What does this bill do? It sends to the States another $25 billion in increased Medicaid costs. What will that mean? Higher tuition rates, higher taxes, or both. The University of California has the reputation as the best public university in the world. It will not be that very long if the Congress of the United States doesn't rein in Medicaid and reduce its cost so Californians can afford to have both a health program and a fine university system. The Governor of Tennessee has said the same thing. He has been outspoken about this. He has talked about exactly the dollars it will cost us. In the House bill, it is $1.4 billion over 5 years. In my view, I don't see how the State of Tennessee can pay that without a big State tax increase or without damaging higher education or both.

Someone might look at this and say: What does health care have to do with a 32-percent tuition increase in California? It has everything to do with it. Instead of reining in Medicaid, we are expanding Medicaid. By doing that, we are making it impossible for virtually every State to properly support higher education. The only choice they have, other than taxes, is raising tuition for 18 or 20 million students across the country. Californians, if this bill passes, your tuition is going up one more time.

I call on the Senator from Georgia, Mr. Isakson. He spent a number of years as the leader of the Republicans in the Senate. He dealt with the Medicaid question. He dealt with the question of taxes. As a small businessman for most of his life, he understands well the impact of new taxes on hiring and mandates on businesses.

I wonder if the Senator would yield for a question?

If the employee were eligible for the Medicaid Program in Georgia and lost employer insurance and went into the Medicaid Program, isn't it true that the employee who went into the new government plan under this bill is likely to pay a higher premium and have a harder time finding a doctor?

Mr. President, I thank the Senator from Georgia. I am going to throw the question right back to Senator Isakson in just a minute.

I appreciate Senator Chambliss taking time to point out what Republicans are for because it seems as if no matter how many times a day we say it, our Democratic friends do not hear it.

Let me put it this way: Let's say Senator Isakson, who has been a small businessman, buys a new small business. He takes it over, and he sees that generally it is working pretty well but

it has some problems with it. I wonder if the first thing he would do is come in and say, I tell you what, let's just turn it all upside down and change it all, or would he say, let's identify the problem, and let's take a few steps in the direction of fixing that problem.

What Republicans are saying is, we have a big health care system that in general works pretty well. Mr. President, 250 million of us have health insurance plans; 47 million do not. Senator Chambliss has just pointed out who those people are. Thirteen million or 14 million are already eligible for plans and for one reason or another do not sign up. A few million are illegally here. Some others are young and think they are invulnerable and do not sign up. But we are saying the problem is the cost, people cannot afford to buy their own insurance, the government cannot afford its health care costs, and people are going broke over this. So we want to reduce the cost.

Senator Chambliss identified this step-by-step approach. He mentioned reducing junk lawsuits against doctors. We have proposals for that. Combating waste, fraud, and abuse--we have introduced legislation for that. Senator Isakson talked about allowing small businesses to pool their resources. Additional ways to reduce cost is allowing people to purchase insurance across State lines, so you can shop for more insurance and reduce your cost through competition, and amending the health savings account laws so you can withdraw your money in a tax- free way to pay for your insurance premium, and encouraging wellness and prevention. We could take those six steps, reduce costs, and then take six more.

I wonder, Senator Isakson, with your experience in business, if you think it makes any sense for us to just come in here and say: OK, we are really smart here in the U.S. Congress. This is a big country, with 300 million people. We are just going to turn the whole health care system upside down, write a 2,074-page bill, change the premiums, raise the taxes--do all these things--or would you go step by step in the right direction and try to re-earn the confidence of the American people who have lost a lot of confidence in Washington, DC?

I say to Senator Chambliss, one of the most difficult issues I think for many Americans who are watching what we are doing is the plan to cut Medicare. The new bill goes a step further. The way I read it--and I indicated the sections in the bill a moment ago--we are not only cutting Medicare, we are going to tax Medicare. Then we are not even going to spend the money on Medicare. In other words, we are going to cut grandma's Medicare, tax grandma's Medicare, then spend grandma's money on somebody else, and grandma's Medicare is going broke in 3 or 4 years, according to the Medicare trustees.

It must be a little confusing to the American people. I mean, one day Senator Reid comes out and, a big hurrah, we are going to reduce the deficit and we are only going to spend $800 billion, and then the next day Republicans come out and say, No, when the program gets going, it is $2.5 trillion over 10 years. I wonder if I could say to the Senator from Georgia, while we have heard you talk about these projections, the senior Republican on the Joint Economic Committee has come to the floor, the Senator from Kansas.

How do you explain this to people in Kansas, Senator Brownback, who must be very confused by this back and forth?

I wonder if I could ask the Senator from Kansas, haven't we heard this story somewhere before? As I remember, back in the late 1960s there was a so-called millionaires' tax. We were going after 155 very rich people in America who weren't paying any taxes and now we call it the alternative minimum tax, and if we don't fix it every year more and more people will end up paying this tax. I think last year there were 28 million Americans who would have had to pay the tax.

I wonder if I might ask Senator Isakson from Georgia, we talked a little bit about his experience as a small businessman. Senator Brownback has talked about taxes and how they are going to go up. According to the Republican Budget Committee analysis, the new taxes in this bill that we have on our desks would be about $850 billion over a 10-year period of time. Senator Isakson has been a small businessperson. Some of those taxes would be on you. Who is going to pay the taxes?

As we were discussing earlier, it could be paid out of the pockets of the 18 million or 20 million students who go to, for instance, the University of Kansas and Kansas State. We began this discussion by pointing out that California raised tuition yesterday 32 percent for its students. They are pointing fingers at each other, but they should be pointing at us for not reining in Medicaid because over time that is the biggest reason.

I have a question I will ask any of the Senators who want to comment. Someone asked me yesterday: Where is all this opposition to these health care bills coming from? We have seen the Gallup poll and the Pew poll. These are not Republican Polls. They are well-respected polls in this country that are showing that independent voters, by 2 to 1, say they don't want this bill.

I have been in and out of politics for many years. I have never had as many people stop me on the street or in the airport or wherever, and say, ``Please don't do this.'' Somebody asked me yesterday: Why is there that much opposition?

My answer was--and this is what I would appreciate comments on--this is not just about health care. This is, as President Obama said one time, a proxy for a national debate about the role of government in Washington and in everyday American life. This is about the stimulus package, about the Washington takeover of car companies. This is about the growing debt; this is about the takeover of student loans; this is about every Washington takeover, and every increase in debt. That is what this debate is about. I think that is why we are seeing such intensive opposition. I wonder if you have any reflection?

I am afraid our time is almost up.

I thank Senators Brownback, Chambliss, and Isakson. I think all four of us want the American people to know above all that we have repeatedly said that instead of 2,000-page bills that raise taxes, raise premiums, cut Medicare, and transfer costs to States, we would rather identify the goal of reducing costs and go step by step toward that goal. We have introduced specific legislation to take those steps, which could be bipartisan, such as allowing small businesses to pool their resources to purchase insurance, that Senator Isakson talked about, and reducing junk lawsuits, as Senator Chambliss talked about, and allowing competition across State lines. We have our step-by-step plan.

We believe the American people have lost confidence in Washington and that they would prefer that we go step by step in the right direction to reduce costs and re-earn their trust rather than pass a 2,074-page bill that will bankrupt the country.

I yield the floor.