A bill to suspend temporarily the duty on acrylic resin solution.

Mr. President, after months of arduous work, the Senate will finally take the first significant step toward bringing needed reforms to health care in this Nation. Opponents of reform have wasted much of the public's time by provoking arguments over their distortions about what health reform means. Opponents have tried to demonize the plan, and have claimed it will never work. We have overcome weeks of delay tactics employed by the minority--inexplicably, the most recent delay due to a filibuster against a bill to provide funding for our troops. These are the tactics of obstruction, and further demonstrate Republicans' efforts to maintain the status quo.

Is this the exact bill that any one of us would have written? Probably not. I remain disappointed that the managers' amendment before us today strips the bill of a public insurance option to compete with private plans and does not include a provision I have sponsored to repeal the antitrust exemption for health insurers and medical malpractice insurers. I believe both of these provisions would go far in providing fair competition into the health insurance market.

But in looking at this bill as a whole, I believe it stands by the core principles I sought at the beginning of this debate. It gives Americans affordable access to health care coverage, it reduces costs for families, businesses and government, and it protects consumers' ability to choose doctors, hospitals and insurance plans.

The managers' amendment introduced by the majority leader incorporates many important changes to the underlying legislation that will improve the bill. It includes several provisions that I have long supported and promoted.

Vermont has always been a national leader in expanding access to health insurance. In coordinating care, offering comprehensive coverage to children, and developing a system of electronic health records, Vermont has been at the forefront of reform. It is no surprise that for the third year in a row Vermont has been ranked the healthiest State in the Nation.

Unfortunately, a provision included in the underlying bill to expand Medicaid coverage nationwide threatened to penalize Vermont by excluding the State from increased Federal funding, solely because Vermont acted early to do the right thing. We can all share the goal of increasing access to essential medical services by expanding Medicaid coverage nationwide, but we should not penalize States such as Vermont, which demonstrated the initiative to expand its Medicaid Program early.

Senator Reid's amendment, however, remedies the anomaly in the underlying bill, and will allow Vermont to access additional Federal funding when the Medicaid expansion goes into effect. I thank Senators Reid and Baucus for working with me to ensure that Vermont's efforts to expand coverage to low income individuals is not set back by inequities in the underlying legislation.

The managers' amendment also incorporates a vital antifraud amendment Senator Kaufman and I, as well as Senators Specter, Kohl, Schumer,

and Klobuchar, introduced, derived from the Health Care Fraud Enforcement Act which we introduced earlier this fall.

This antifraud initiative builds on the impressive steps the administration has already taken to step up health care fraud prevention and enforcement, and on the real progress represented by the antifraud provisions adopted by the Finance and HELP Committees and incorporated into the leader's health care reform bill. I was glad to contribute to those efforts, and I am glad we are now going even further.

The Kaufman-Leahy provision will provide prosecutors with needed tools for the effective investigation, prosecution, and punishment of health care fraud. By making modest but important changes to the law, it ensures that those who drain our health care system of billions of dollars each year, driving up costs and risking patient lives, will go to jail, and that their fraudulent gains will be returned to American taxpayers and health care beneficiaries.

For more than three decades, I have fought in Congress to combat fraud and protect taxpayer dollars. This spring, I introduced with Senator Grassley and Senator Kaufman the Fraud Enforcement and Recovery Act, the most significant antifraud legislation in more than a decade. When that legislation was enacted, it provided law enforcement with new tools to detect and prosecute financial and mortgage fraud. Now, as health care reform moves through the Senate, I am glad we are taking steps to do all we can to tackle the fraud that has contributed greatly to the skyrocketing cost of health care.

The scale of health care fraud in America today is staggering. According to even the most conservative estimates, at least 3 percent of the funds spent on health care are lost to fraud--more than $60 billion a year. In the Medicare Program alone, the General Accountability Office estimates that more than $10 billon was lost to fraud just last year. While Medicare and Medicaid fraud is significant, it is important to remember that health care fraud does not occur solely in the public sector. Private health insurers also see billions of dollars lost to fraud. That fraud is often harder for the government to track. Private companies have less incentive to report it, and in some cases, are responsible for the fraudulent practices themselves. Reining in private sector fraud must be a part of any comprehensive health care reform.

The Kaufman-Leahy provision makes a number of straightforward, important improvements to existing statutes to strengthen prosecutors' ability to combat health care fraud. The bill would increase the Federal sentencing guidelines for health care fraud offenses. Despite the enormous losses in many health care fraud cases, offenders often receive shorter sentences than other white-collar criminals. This lower risk is one reason criminals are drawn to health care fraud. By increasing the Federal sentencing guidelines for health care fraud offenses, we send a clear message that those who steal from the Nation's health care system will face swift prosecution and substantial punishment.

The provision provides for a number of statutory changes to strengthen fraud enforcement. For example, it would expand the definition of a ``Federal health care fraud offense'' to include violations of the antikickback statute and several other key health care-related criminal statutes, which will allow for more vigorous enforcement of those offenses, including making their proceeds subject to criminal forfeiture. It also clarifies the intent requirement of another key health care fraud statute in order to facilitate effective, fair, and vigorous enforcement.

The managers' amendment also includes our provision amending the antikickback statute to ensure that all claims resulting from illegal kickbacks are considered false claims for the purpose of civil action under the False Claims Act, even when the claims are not submitted directly by the wrongdoers themselves. All too often, health care providers secure business by paying illegal kickbacks, which needlessly increases health care risks and costs. This change will help ensure that the government is able to recoup from wrongdoers the losses resulting from these kickbacks.

The Kaufman-Leahy measure gives the Department of Justice limited subpoena authority for civil rights investigations conducted pursuant to the Civil Rights for Institutionalized Persons Act. This provision allows the government to more effectively investigate conditions in publicly operated institutions, such as nursing homes, mental health institutions, and residential schools for children with disabilities, where there have been allegations of civil rights violations.

These changes will strengthen our ability to crack down on fraud and will ultimately result in significant savings that will make health care more efficient and more affordable.

I am also pleased Senator Reid's amendment includes a key reform to the False Claims Act that Senator Sanders, Senator Grassley, and I have proposed. By fixing the False Claims Act's public disclosure provision, we can ensure that we fairly and appropriately empower whistleblowers to come forward to expose fraud, which is a crucial way to save the government money and ensure the health and well-being of Americans.

We all agree that reducing the cost of health care for American citizens is a critical goal of health care reform. We in Congress must do our part by ensuring that, when we pass a health care reform bill, it includes all the tools and resources needed to crack down on the scourge of health care fraud. This provision is an important part of that effort.

I am also very encouraged that the amendment before us includes a measure I proposed with Senator Brown to expand Federal Tort Claims Act medical malpractice coverage for free medical clinics. This expanded coverage will help free clinics across the Nation continue to provide and improve a critical safety net for many Americans.

In 1996, Congress enacted legislation to cover volunteer medical professionals in free clinics with medical malpractice liability insurance through the Federal Tort Claims Act. This coverage protects volunteer medical staff against liability by substituting the Federal Government for an individual defendant. But without any explanation in the legislative history, the coverage enacted in 1996 failed to provide coverage for others who are essential to the operation of free clinics, such as nonmedical staff, contractors, board members, and the clinic itself. As a result, free clinics must use scarce funding to purchase insurance on the private market to fill this gap. This lack of comprehensive coverage for free clinics is inconsistent with the coverage provided to community health centers, which benefit from coverage for all employees. This provision will remedy this discrepancy.

This measure will have no impact on the legal rights of a patient injured by a medical error; any victim of medical malpractice will still be able to pursue a remedy for an injury under the Federal Tort Claims Act. Instead, this amendment will free up scarce resources that are currently being used to purchase liability insurance on the private market. Informal estimates indicate that this amendment could save free clinics across the country $15 to $20 million a year. These are funds that will be redirected to providing essential medical services to low- income and other Americans in need. For example, as a result of this amendment, the Viola Startzman Free Clinic in Wooster, OH, will save $17,000 a year. The Americares Clinic in Stamford, CT, will save $31,000 each year. Our hard-working free clinics in Vermont will save $12,000 each year and will be able to put those savings toward helping Vermonters in need of health care services. For free clinics operating through volunteerism and private donations and in a difficult economy, these are substantial sums that if devoted to the care of Americans in need will have a significant positive impact.

And the savings realized through this amendment will cost the taxpayers little if anything. Free clinics do not perform high-risk procedures such as obstetrics or surgeries, and thus are subject to a lesser risk of liability. Since 2004, when funds were first appropriated and set aside to cover any claims against free clinic doctors, no claims have been filed. The bottom line is that this amendment represents significant value to Americans in need of

health care services at little cost to the government and the taxpayer.

I thank Senator Brown for his support as a cosponsor, and I thank the majority leader, Senator Harkin, and Senator Baucus for working with me to make this amendment part of the historic legislation before the Senate.

Over the course of the past month, I have listened to many of my friends on the other side of the aisle. It is not surprising that frequently they have argued for one of their pet proposals--medical malpractice reform. For as long as I have served in this Chamber, I have fought against court-stripping measures that limit American's access to their justice system. I have also fought to protect the sovereignty of States to make rules for their own justice systems. Medical malpractice claims are based on State law and for the most part take place in State courts. I find it curious that some of the same Senators who pledge loyalty to federalism and the sovereignty of the States under the tenth amendment are some of the same Senators who are so aggressively pushing for a Federal ``one-size-fits-all solution'' for the justice systems in our 50 States.

The managers' amendment includes a provision addressing malpractice liability that has been introduced on a bipartisan basis several times over the past few years. I support this provision because it respects the States' primary role in adjudicating the claims of patients injured or killed by medical errors. I also support this provision because it resists the notion that ``one-size-fits-all'' when it comes to litigation issues and it includes the necessary safeguards for patients. I note for the Record that several States' efforts to reform medical malpractice liability have been struck down as unconstitutional. For example, Alabama, Florida, Georgia, Illinois, Kansas, New Hampshire, Ohio, Oregon, South Dakota, Washington, and Wisconsin have all enacted caps on damages associated with medical malpractice claims. And all of those State laws were struck down as unconstitutional for good reason. I am heartened that no such amendment was seriously considered in this Chamber because such arcane measures hurt our children, our senior citizens, and stay-at-home moms. The Wall Street Journal has reported on this clear fact when it pointed out that these caps deprive these groups of access to justice. If we create Federal caps on their ability to recover from serious injuries we are telling them that they are worth less because they are retired or they choose to stay home and raise a family or are young children. This is not fair. I know that no doctor wants to harm a patient, but the solution is not to take away the rights of patients who are seriously injured.

The provision in the managers' amendment does not encourage draconian damages caps and does not dictate what reforms States must consider. Importantly, however, it does include specific patient protections that must be in place before a State can receive a grant for liability reform measures. To the extent that States can pass measures that improve patient safety as well as expedite damages recovery for victims, those reforms will truly improve our health care system.

I am disappointed, however, that the Health Insurance Antitrust Enforcement Act, which I introduced in September, was not part of the managers' amendment, and will not be part of the Senate's health reform legislation. That legislation would repeal the antitrust exemption for health insurers and medical malpractice insurers, and is an integral part of injecting competition into the health insurance market.

While there are differing views on the best way to inject competition into the health insurance market, we can all agree that health and medical malpractice insurers should not be allowed to engage in blatantly anticompetitive practices, such as colluding to set prices and allocating markets. My repeal would ensure that basic rules of fair competition will apply to insurers, and is nonpartisan.

My amendment was cosponsored by 23 Senators, and has support from a cross-section of consumer rights organization. I look forward to working to include this repeal when the Senate and House conference to reconcile their versions of the legislation.

The managers' amendment will improve the underlying bill, and I hope my fellow Senators will support its passage so we can move toward final passage of the bill. Each day that passes without reform, 30 more Vermonters lose their health insurance. We know our current health system is unsustainable. That threatens not only our health security, but also our economic security. Doing nothing has been seen as an option before, but it simply is not an option now.

I hope now we can work together to pass a bill that will give millions more Americans access to quality, affordable health care. We should reject the tactics of delay and the efforts to obstruct, and remember that the Senate should be the conscience of the Nation. With the Christmas season upon us, our constituents are looking to us to do the right thing. We should adopt this amendment, advance this legislation, and work to send it to the President without undue delay.

Mr. President, I guess I can say we crossed the Rubicon last night at 1 o'clock. Reading some of the press reports, of course, most of the news didn't have it because it occurred at 1 a.m. Some of the different reports have been online this morning. It occurred to me that a lot of people are missing the overall importance of what happened last night. We can get into the fine tuning and the nitpicking and sort of the fear and the anger I hear from the other side. Every time I listen to speeches over there, with the exception of the last speaker, almost all the speeches I hear from the other side, it is fear, be afraid, be afraid. It is some built-up anger over there. I think what happened last night is, we crossed a demarcation line, the demarcation line of which on one side health care is a privilege. We have been on that side of the line for a long time. On the other side of that line, health care is a right. We stepped across that line last night. We are now in the process of saying health care is a right, an inalienable right of every American citizen.

Is that what so upsets my friends on the Republican side? I don't know. Something is upsetting them. Because this is a momentous change we are doing.

I keep hearing from Republicans they want us to deal in a bipartisan way. We tried all this year, both in the HELP Committee and in the Finance Committee. Senator Baucus bent over backward to accommodate. But at every turn, Republicans said no, no, no, no, no--all year long. How can you be bipartisan when the other side has nothing to offer? There is no bill on the Republican side. There is a bill. It has about nine cosponsors--Senator Coburn, Senator Burr, maybe seven others, but not every Republican is on that. I hear bits and pieces of this and that every time I hear these speeches. Most of it is attacking what we have done. I hear nothing positive from their side. It is very hard to deal with a party that is in total disarray as the Republicans are. If they had a bill they were supporting and that was supported by all of them, such as the bill we have here which is supported by 60 Democrats, I think then you could find some reason for meeting and working things out. But since there is no one on that side who has a comprehensive proposal, it is hard to do that. We have had to kind of plow ahead as best we can. We have not done this alone. In our committee, we met for 13 days. We had 54 hours of markup. No amendment was denied. Republicans offered over 200 amendments. We adopted 161 of them. That is pretty good. Yet in the end, every Republican voted against it. So it is not as if we didn't try and we didn't hold out an olive branch to work with people to get a bill that was truly bipartisan. We did in our committees, both the Finance and HELP Committees. Now it has come down to fear and anger on the other side and some nitpicking.

My friend from Iowa--and he is truly my friend--was talking about some provisions put in the bill for special reasons and so forth. I admit fully and openly that I was part of that. Did I put something in the bill that was sort of particular to my State of Iowa? Yes, I did. But it doesn't just affect Iowa. There are several States in which we have hospitals that are not as big as the big hospitals with the volume. They are not so small that they are low-volume hospitals that get help. They are kind of in between. They call them tweener hospitals. We have eight of them in Iowa: at Grinnell, Keokuck, Spencer Municipal, in Carroll, St. Anthony Regional; Muscatine; Fort Madison; and Lake Regional Hospital at Spirit Lake. There are a number of these in the United States. I forget the total number; not a large number, they just fall in a place where they are too small for the big and too big for the small. As a result, they have been getting a bad deal from Medicare reimbursement. There is a fix in this bill that will allow them to get adequate reimbursement. I don't see anything wrong with that. It is fixing a specific problem that the bureaucracy can't seem to quite get fixed. That is in the bill. I make no bones about having put that in there. I think it is a good deal. It is something that is going to help a lot of hospitals, not only in Iowa but a few other States.

One of the things I wish to talk about today is something I have been on for many years, and that is the huge amount in this bill on prevention and wellness. It has not been written about a lot. People have been focused on the public option and the abortion issue and a few other items such as that. Perhaps one of the most profound parts of this bill and the one I believe will do more to bend the cost curve, as they say, than any other single thing is the provisions dealing with prevention and wellness. In the past I have said many times that we don't have a health care system in America. We have a sick care system. When you think about it, if you get sick, you get care. But precious little is spent out there to keep one healthy in the first place. So people get sick. You go to the doctor, the hospital. We patch and fix and mend and try to make them well.

Your mother was right, you know: Prevention is worth a pound of cure. We have fallen far short of that in this country. There is a remarkable array of provisions in this bill that promote wellness, disease prevention, and public health. Together they will move us from a sick care society into a genuine wellness society, into a true health care system, not just sick care. What better way to reform our health care system than to restrain health care costs by helping Americans to prevent chronic diseases, stay healthy and out of the hospital in the first place. Right now, as we have heard so many times, we spend more than $2 trillion each year on sick care. But 4 cents of every dollar is invested in prevention and public health. I submit this is a major reason why Americans spend twice as much per capita on health care as European countries, but we are twice as sick with chronic disease. We spend twice as much as Europe on health care, but we are twice as sick with chronic diseases.

The good news is that by ramping up the emphasis on wellness and prevention, we have tremendous opportunities to both improve the health of the American people and to restrain health care spending. That is the aim of this bill which makes significant new investments in prevention. For example, our bill would ensure that seniors have access to free annual wellness visits and personalized prevention plans under Medicare. We have never had that. For the first time seniors will have access to free annual wellness visits and personalized prevention plans under Medicare. That is a big deal. So many seniors today, if they get sick, go to the doctor and get more pills. Now they will be able to go in, have their annualized checkup, see what is wrong, and have a personalized prevention plan for each person under Medicare.

It will also encourage States to improve coverage and access to recommended preventative services and immunizations under Medicaid. At a minimum, States will provide Medicaid coverage for comprehensive tobacco cessation services for pregnant women. That is just the start. Right away, at a minimum, they have to do that. In addition, the bill requires insurance companies to cover recommended preventive services with no copayments or deductibles. This is critical because we know that all too often people forgo their yearly checkups or essential screenings because either their insurance companies don't cover them or because they have high copays and deductibles.

Another critical element in the bill essential to a sustainable push for wellness is the creation of a prevention and public health trust fund. Typically prevention and public health initiatives are subject to unpredictable and unstable funding. This means that important interventions, things such as education about nutrition and assistance for smokers who want to quit,

often go unfunded from one year to the next. They get funded a little bit one year or cut the next; funded a little bit the next year, cut the next. The prevention and public health fund in this bill will provide an expanded and sustained national investment in programs that promote physical activity, improve nutrition, and reduce tobacco use. We all appreciate that checkups and immunizations and other clinical services are important. But this bill also recognizes that where Americans live and work and go to school also has a profound impact on our health. That is why a number of provisions in the bill focus on creating healthier communities with better access to nutritious foods as well as safe places to engage in physical activity.

A 2007 study by the Trust for America's Health found major savings from community-based prevention programs designed to increase levels of physical activity, improve nutrition, and reduce smoking rates. This study concluded that a national investment of $10 per person per year in these kinds of community-based programs could yield net savings of more than $2.8 billion annually in health care costs in the first 1 and 2 years, more than $16 billion savings within 5 years, and nearly $18 billion savings annually within 10 to 20 years, starting at $10 per person per year.

More generally, this bill aims to give Americans the tools and information they need to take charge of their own health. For example, it requires large chain restaurants to post basic nutrition information on the menu so consumers can make healthy choices. That is in this bill. It will start next year.

The bill also focuses on prevention and public health needs of a number of generally overlooked populations, including children, individuals with disabilities, Americans living in rural communities, and certain ethnic minorities. For many months I have made the case that it is not enough to talk about how to expand insurance coverage, how to pay the bills--those are important--but it makes no sense to figure out a better way to pay the bills for a system that is dysfunctional, ineffective, and broken.

We have to change the health care system itself, beginning with a sharp new emphasis on prevention and public health. We also have to realize that wellness and prevention must be truly comprehensive. It is not only about what just goes on in the doctor's office; it also encompasses community-wide wellness programs, about which I just spoke, things such as building bike paths, walking trails, getting junk food out of our schools, out of the vending machines, making our school breakfasts and lunches more nutritious, increasing the amount of physical activity our children get, and so much more.

Some of this is going to be addressed in other bills. For example, next year, in the Agriculture Committee, we will be reauthorizing the child nutrition bill. That deals with school lunches and school breakfasts. We need a major effort there to make our lunches and our breakfasts more nutritious for our kids in school.

Next year, in the committee I chair, the HELP Committee, we are going to reauthorize the Elementary and Secondary Education Act, the so- called No Child Left Behind Act. There are a lot of things we are going to be doing on that. I see one of our committee members, the Senator from Colorado, Mr. Bennet, in the Chamber, a former superintendent of schools, who is going to play a key role in helping get that Elementary and Secondary Education Act through and refined and brought up to date where we will make some changes.

But there is one other part of that bill we have to focus on; that is, the amount of physical activity kids get in school. I talked many times both to Secretary Duncan and, before him, to Secretary Spellings about this idea of No Child Left Behind. If we are not going to leave kids behind in terms of their writing and their math and their English, how about not leaving them behind in terms of their health? Yet recess is gone. I saw a statistic this year that said 80 percent of elementary school kids in America today get less than 1 hour of physical exercise a week in school--80 percent get less than 1 hour a week.

Mr. President, I do not know about you, but I remember when I was in school, in elementary school, we had an hour a day for recess. We had 15 minutes in the morning, 15 minutes in the afternoon, and a half hour at lunch. So there was 1 hour every day, and we had to go out and do stuff. We couldn't sit around and play with Game Boys and things like that. So we got an hour a day of physical exercise. Well, we need to reinvigorate our schools to make sure they get that physical exercise.

So we have done a lot in this bill to move this paradigm toward a health care society rather than a sick care society. There is more to do, as I said, in both the Education bill next year and in the Agriculture Committee in terms of the child nutrition reauthorization. But in this bill we have made a great start. We have laid a great foundation. I am just thrilled so many of the wellness and prevention initiatives I have championed for so many years are included in this bill.

As I look forward to going to conference, we look forward to working with the House to strengthen it even more and to put more emphasis on wellness and prevention.

Just about an hour ago or so, we had a press conference with the president-elect of the American Medical Association, Dr. Wilson. I am proud of the fact that the American Medical Association has now endorsed our bill. As I said at the time, I said the doctors of America have examined this bill, and they have made the right prescription: Pass it. Pass the health care reform bill.

But Dr. Wilson, in his statement, made particular note of the wellness and prevention programs we have in this bill. He did not say this, but I was thinking, when he was talking, that it made sense. Doctors want to keep people healthy. They do not want to see people go to the hospital. They would rather be working with their patients one on one. How can they structure a patient's profile so the patient stays healthy, does not get sick so often? That is what Dr. Wilson was talking about: letting doctors practice medicine in a way that focuses on a person's health and keeping them healthy.

As President Obama said in his speech to Congress early this year:

[It is time] to make the largest investment ever in

preventive care, because that's one of the best ways to keep

our people healthy and our costs under control.

That was the President of the United States in his State of the Union message. Well, President Obama has it right. It is one of the best ways to keep our people healthy and our costs under control, and that is a big part of this bill. I do not know--I have not listened to every speech made by the Republicans on the other side--but I hardly ever hear them talk about this, but it is a very important part of the bill.

So, Mr. President, we are changing the paradigm. We are going to extend quality, affordable health coverage to nearly every American. We are going to transform ourselves into a genuine wellness society, and we are going to give our citizens access to a 21st-century health care system, one that is focused on helping us to live healthy, active, and happy lives.

Mr. President, I yield the floor.

Madam President, the Senator from Wyoming is correct. Of course, we would like to offer amendments. I know the Senator from Wyoming has deep experience in this field, being a practicing physician, someone who brings great knowledge and background to the debate and obviously has great insight about how this 2,100-page bill could be improved upon. What we have here is the 2,100 pages that we started with, and this represents one-sixth of our entire economy. We are talking about reordering one-sixth of the entire economy. Saturday we received an amendment, a 400-page amendment which nobody up until Saturday had seen. In fact, many of the Democrats hadn't seen it either, including members of the Democratic leadership. There was a discussion on the floor last week between Senator McCain and Senator Durbin in which Senator McCain said: They are writing this amendment behind closed doors. We don't have any idea what is in it. The Senator from Illinois, the No. 2 person in the Democratic leadership, said: I am in the dark just like you are. You had a handful of people who were adding 400 pages of content to the 2,100 pages we already have.

In addition, there is another amendment that adds another 300. We are talking about 2,700 pages that will reorder and restructure literally one-sixth of the entire American economy. Right now what we are being told is that we are not going to be allowed to offer amendments to that humongous piece of legislation. When you get this much legislation coming at you and receiving this on Saturday, not having the opportunity to read it for the first time, is why we have been saying we need to push this back and not try to jam it through before the Christmas holiday. You find all kinds of things in these bills. Sometimes people take credit for those being there. Sometimes they don't. We have had a debate about some of the provisions that benefit specifically Nebraska. You have this Medicaid provision that requires the taxpayers of the other 49 States to subsidize and pay the Medicaid matching share for the State of Nebraska which will cost millions and millions of dollars. The Senator from Arizona mentioned this late add, a $100 million item for construction of a university hospital which, again, is being reported as being inserted by the Senator from Connecticut. You have all these sorts of deals that get made to try and get that elusive sixtieth vote that are now coming to light. The American people have a right to know it. Frankly, Members of the Senate who have to vote on this have a right to know what is in these volumes of pages, 2,700 pages, that will spend $2.5 trillion. The original 2,100-page bill spent $1.2 billion per page, $6.8 million per word. It creates 70 new government programs. This is a massive overhaul of health care delivery.

What it ought to be about is driving down the cost of health care for people. In fact, we have heard a lot of discussion from the other side about how this drives down the cost of health care. This bends the cost curve down. They can say that, but the experts we rely on, the referees or the umpires, say otherwise. In fact, what the CBO has said is that the cost curve would be bent up by this bill. The blue line on this chart represents the increasing health care costs year over year if we do nothing. The blue line represents what we would be looking at if we continue on the current course which everybody here acknowledges is unacceptable. We all want to see the cost

curve go down and see overall health care costs go down. But the ironic thing is, according to the CBO, the red line represents what happens if the bill proposed by the Democratic majority actually becomes law. The cost curve is bent up. We will actually spend more on health care than we are spending today, even the year-by-year twice the rate of inflation increases in health care premiums today.

The Senator from Wyoming is absolutely right to be offering amendments to address the issue of premiums. This bill does not do anything to reduce premiums for most Americans. About 10 percent of Americans, because of the subsidies in the bill, would get their premium costs reduced, but 90 percent--we are told by the CBO--would see their premiums stay the same or go up. When I say stay the same, it means go up at the current rate of twice the rate of inflation. Worst- case scenario, if you are buying your insurance in the individual marketplace, you will see your insurance premiums go up above and beyond this by 10 to 13 percent. Health care costs for 90 percent of Americans, the best they can hope for, is the status quo which is year- over-year increases that are twice the rate of inflation. If you are one of the unlucky who buys their insurance in the individual marketplace, your premiums go up by another 10 to 13 percent. This ought to be about driving down health care costs and getting premiums under control.

The overall cost of health care in this country represents about one- sixth of our entire economy. If this bill passes, according to the Congressional Budget Office, according to the Actuary of CMS, health care spending will no longer be one-sixth of the economy; it will be more than one-fifth. Because if this bill passes, health care spending will go up to about 21 percent of our gross domestic product.

Tell me, what does this bill do then to get costs under control? If we are driving up the cost of health care for individuals in the form of higher premiums, if we are driving up the overall cost of health care as a percentage of our economy, why would we be jamming this thing through before the Christmas holiday, these 2,700 pages, spending $2.5 trillion of taxpayer money, raising taxes on small businesses, which obviously have weighed in on this, and the National Federation of Independent Business, which represents a lot of small businesses around the country, has said, if enacted, this bill would cost us 1.6 million jobs because of all the new taxes it imposes--you are raising taxes, when fully implemented, by about $1 trillion, cutting Medicare by about $1 trillion. After all that, what do you have? You have the same or worse insurance premiums for 90 percent of Americans. I argue that is a bad deal for the American people.

Coming back to the special deals, this is not the way to legislate. To carve out deals, to go and try and find or buy or however you want to characterize it that sixtieth vote is essentially what we are talking about. These are special goodies packed into this bill essentially because the majority decided that rather than trying to include Republicans and pass it with Republican votes, they had to pass it with all Democrats which meant that every one of the Democrats had tremendous leverage. Clearly, they decided to use it. There are lots of carve-outs, lots of special deals in this that cost the American taxpayers hundreds of millions of dollars in additional spending simply because they wanted to get this done by an artificial deadline and wanted to do it with all Democratic votes.

I say to my colleagues, this process itself, when the American people find out about particularly this latest deal, smells. I don't think they are going to like it. I don't think they are going to like the end product when they find out it will raise insurance premiums.

If the Senator will yield on that suggestion of small business health plans, doesn't that enjoy wide support among small businesses in this country?

If I might continue, the one thing that strikes me about this proposal that, as I said before, now is, in totality, 2,700 pages, is that it does not enjoy any support from any small business organization that I know of. Maybe there are some out there I cannot speak to. But I do know the organizations that represent small businesses that we are all well acquainted with--National Federation of Independent Business, the Chamber of Commerce, the National Association of Manufacturers, the National Association of Wholesalers and Distributors, builders and contractors, electric contractors, franchise associations--I can go right down the list--all say this does nothing to lower their costs. In fact, it increases the cost of doing business, increases the cost of doing health care.

What they have argued repeatedly is one of the suggestions the Senator from Tennessee mentioned, that small business health plans would drive their health care costs down, which is why they have been such strong advocates for this over the years.

I guess the other question I would ask of my colleague from Tennessee is, would an approach, a suggestion like small business health plans require tax increases that would hit small businesses?

Incidentally, the latest version with the managers' amendment, which we just received Saturday, increases the tax increases in the bill that were previously $493 billion and are now $518 billion. As the Senator mentioned, with the tax credit businesses get, they up that a little bit but not enough to help most small businesses in light of the $518 billion in tax increases in the first 10 years, and when it is fully implemented it will be about $1 trillion. But the payroll tax that is going to hit a lot of small businesses was increased dramatically in the managers' amendment. The individual mandate was almost doubled in the managers' amendment. So the taxes in the bill go up with this proposal.

I guess my question is, with all these tax increases that are going to have a crushing impact on small businesses, does a suggestion such as the one made by the Senator from Tennessee for small business health plans require tax increases or Medicare cuts, which is what is going to be necessary to finance this 2,700-page behemoth?

I appreciate the Senator for his work on that issue. It is a view I share, a proposal I have been a big advocate of going back to my days in the House of Representatives and one which, as the Senator from Tennessee noted, has tremendous support among small businesses across the country. About the only place it does not have majority support is here in the U.S. Congress because maybe it makes too much sense.

But it seems to me there are suggestions and solutions out there which do not require $\1/2\ trillion of tax increases on small businesses, which every small business organization has come out and said: It is going to drive up our cost of doing business, and at the end of the day, it is going to raise our health care costs--and does not require these steep Medicare cuts that the Senator from Wyoming has alluded to over and over again and the impacts those will have on the delivery of health care to seniors across this country but, rather, it would bend the cost curve down without tax increases and Medicare cuts.

Another example of that, I would argue, would be allowing for interstate competition, allowing people to buy their insurance across State lines, which is a suggestion we have made over and over on our side of the aisle. According to the Congressional Budget Office, both small business health plans and buying insurance across State lines actually would reduce health care costs and would do it without raising taxes or cutting Medicare, which, to me, would make a lot of sense, especially when you have an economy in recession, 10-percent unemployment, a $1.5 trillion deficit last year and another $1.5 trillion deficit this coming year, and when you are talking about a $2.5 trillion cost in the growth of government here in Washington, DC, to implement these 2,700 pages.

Some suggestions along the lines of the one mentioned by the Senator from Tennessee and some of these others would make a lot of sense, and I think they would enjoy tremendous support among small businesses, which create the jobs in this country, as well as among the American public.

So I thank the Senator from Tennessee for pointing out one of the many things Republicans are for and which we have tried to get in the debate.

I know the Senator from Wyoming has advocated for many of these same types of initiatives and solutions. As he mentioned earlier, he was prepared to offer an amendment to address the issue of premiums, but it looks as if we are going to be prevented from doing that.

If the Senator from Wyoming would yield on that point, that is why I think day after day after day--and I have said--there is a pattern emerging here in the Senate where the majority comes down and establishes the need for health care reform, which we all acknowledge, and illustrates examples of those who have fallen through the cracks, which we all know examples exist--all of us have dealt with those in our individual States--and then proceeds to attack Republicans for not having their own ideas, which we have just mentioned there are lots of good Republican ideas which do not raise taxes, which do not cut Medicare, and actually do something to reduce premiums. But that seems to be the strategy employed and the pattern that emerges in the rhetoric day after day down here from the other side.

The one thing I do not hear is them coming down here and talking about what this 2,700-page bill is going to do to reduce health care costs, because if we all submit to the experts on this--which, as I said earlier, the Congressional Budget Office is sort of the referee. They do not have a political agenda, or at least they are not supposed to. The Actuary at the Centers for Medicare and Medicaid Services does not have a political agenda, or at least they are not supposed to. They are sort of considered to be an umpire on this. The Joint Committee on Taxation, which looks at the distributional impacts of tax policy, is a referee and is not supposed to have a political agenda in all this. They all come to the same conclusions with regard to premium increases in this bill.

So if the overall objective is to reduce the cost of health care, and if, in fact, your legislation, according to all the referees, all the umpires, all the experts, not only increases premiums for most Americans but increases the overall cost of health care, which is what they all conclude, it is pretty hard to come down and defend this product. That is why I think day after day they try to create distractions and counterattacks as opposed to actually coming down and talking about the substance of the bill because the substance of the bill does not accomplish the stated objective, which is to reduce the overall cost of health care and get premiums under control for families and small businesses in this country.

It is also hard, I would argue, because of the $518 billion of tax increases that are in here and the unified opposition of the entire small business community, which creates 70 percent of the jobs in this country, to talk about how this can be anything but detrimental to job creation. This is going to cost us jobs. I think every business organization has made that abundantly clear. And all the analysis of this legislation that has been done comes to the same conclusion.

Mr. President, I just heard my colleague, the Senator from Ohio, say: I wish some of my colleagues on the other side of the aisle would understand families who don't have insurance.

I practiced medicine for 25 years, taking care of families in the State of Wyoming. During that time, I took care of all patients, regardless of their ability to pay. I will tell you, I believe, as a physician who practiced medicine for 25 years--and as someone whom the Obama administration has decided to completely ignore, as he did the other Senator of this Chamber who is a physician--that I know specifically and personally about what happens to families who lose their insurance. My colleague and I know specifically what happens to families who are on Medicaid, a health care program which my colleague who is now leaving the Chamber after asking if anyone in this body understands people without insurance but not staying to hear the discussion for the next hour--making statements and then leaving--I understand those families. I understand the families on Medicare, I understand the families on Medicaid, I understand the families without insurance, I understand the families worried about losing their insurance, I understand about the families worried about disease.

My colleague from Ohio said: Do people understand women with breast cancer? Well, my wife is a--

Regular order, Mr. President.

My wife was a breast cancer survivor, and her breast cancer was discovered in her forties by a screening mammogram. It was that screening mammogram that saved her life because the cancer had already spread. It had already spread to a lymph node. She had three operations, two bouts of full chemotherapy, radiation--35 treatments and all--all--because of the screening mammogram that saved her life. Yet because of this bill that was brought to the Senate floor--with the government knowing better than the rest of America, knowing what health care ought to be given and shouldn't be given--all of a sudden what we see is the government knows best, people don't know--her life would have been lost because she is one of those 1,900.

So I understand, having practiced medicine, having lived that life as a physician--taken care of people without health insurance and on Medicaid and Medicare and those worrying about losing their insurance when they lose their job--the implications. Yet I took care of all of them, as did all my partners. We dealt with all these people, trying to help each and every one of them, regardless of their ability to pay. It is why we need health reform in this country that actually works on availability of care, affordability of care, access to care, and quality care. This bill that I voted against last night doesn't address the needs of the country. It fails time and time again.

The President made a number of promises--a number of promises--to the people of this country. He said people would see their insurance premiums drop by $2,500. Instead, the budget officers say: Oh, no, it is going to go up $2,100 for a family. Has the President not read the bill, not read the responses that have come from the Congressional Budget Office? Does he not see the difference there of $4,600 per family?

The President said this wouldn't add a dime to the deficit. Well, it is going to add a lot of dimes to the deficit. This is going to add $1 trillion to the deficit. He said: Oh no, will not at all. Yet they didn't do the doctor fix--the Medicare doctor fix. Now the Speaker of the House says: Oh, we will handle that in January or February for $250 billion, since they are not going to pay for it here.

The President said: Taxes will not go up on anybody making under $250,000 for a family. There are a dozen taxes in the bill that will be passed on to the American people. Now any teenager who goes to a tanning salon is going to get taxed 10 percent. I don't think any of those people are making over $250,000 apiece.

The President said: People will not lose their coverage. Oh, they are going to lose their coverage. Many will lose the coverage they have, coverage they like, because they have cut 11 million people on Medicare Advantage--a program people like, a program my patients like. People whom I have taken care of like it because there is actually an advantage to the program. It is a program that deals specifically with preventive care. It is coordinated care. That is what happens with Medicare Advantage. The President doesn't like. They will lose their coverage.

Of course, the President said we wouldn't see any cuts to Medicare. Yet the bill says $500 billion of cuts to Medicare for the seniors who depend upon Medicare.

The President said we would have an open, honest debate. He said C- SPAN would be there covering the debates. Those of us with the most experience--the two physicians, with 50 years in the practice of medicine and taking care of families in this country--were completely excluded--completely excluded--even though we offered to go to the White House and read the bill with the President.

So what do we have? What is the verdict of the American people on the vote that was taken in the dark of night--at 1 a.m. in the morning--a Monday morning vote, taken at 1 a.m. so the American people, hopefully, according to the Democrats, would be asleep and not see what they were doing to the American people? The verdict is the American people are overwhelmingly opposed--opposed--to the bill the Senate last night voted 60 to 40 on cloture and decided to move ahead on.

The deals in the bill are absolutely astonishing: $100 million for a hospital in a State we still can't identify and no one is claiming, a payoff to one State, a payoff to another State, and then the cuts in Medicare for our seniors who depend on Medicare, a program that is going to go broke in the year 2017--not to save Medicare. Instead of saving Medicare, to start a whole new government program.

I see my colleague from the State of Tennessee is standing, and he has worked closely with people on Medicare in his home State. He is familiar with that and with Medicaid and he knows how difficult it is for patients to get to see a doctor. With the cuts in Medicare, it is going to make it harder for those hospitals to stay alive and open in your community, and for patients to get the kind of care they need.

So I would ask my friend from Tennessee: Are there concerns you have about the cuts to Medicare and how they are going to impact on the care of people in your home State?

Mr. President, what you are hearing is what we are noticing as Republicans take a look at the bill. I saw the majority whip come onto the Senate floor a few minutes ago. Yesterday he was on the floor and said the Republicans have not offered amendments to this bill, so I brought four amendments yesterday. The chairman of the Finance Committee objected.

One had to do with letting people on Medicare keep their own doctors or choose who they want to go to see for a doctor. The purpose of this what was called ``Medicare Patient Freedom to Contract'' is it ``allows Medicare patients the right to privately contract for medical services with the physician of their choice.''

I ask my friend from Tennessee, who has just spoken about Medicare, wouldn't he think that patients who have been promised that they can keep the health care they want should be able, or at least this Senate ought to be able to debate an amendment about allowing Medicare patients the right to privately contract for medical services with the physician of their choice? Wouldn't that seem fair?

Another amendment--I see my colleague from South Dakota is here--is an amendment I offered on the floor of the Senate yesterday to protect individuals from skyrocketing insurance premiums. You may recall the President of the United States said premiums--families in Wyoming and other States, families across the country--health insurance premiums would go down $2,500 per family. Yet what I read and studied, and as I look at this, it says to me it looks like premiums will go up instead of going down. Instead of going down $2,500, they will go up $2,100. I think for 90 percent of the families in this country, their insurance premiums will either stay the same or go up more because the bill is passed than if we did nothing.

I ask my friend from South Dakota--I know he has been bringing forth information; I know he put a chart together on it--would there not be some value in allowing the Senate to discuss an amendment because this amendment basically said let the State insurance commissioners--because every State has an insurance commissioner--let the State insurance commissioner take a look at what happens to insurance premiums in their State. If the insurance commissioner finds that the premiums have gone up faster than the Consumer Price Index, then in that State where those premiums have gone up faster than the Consumer Price Index, all of these laws and regulations and rules would no longer apply. The mandates, the rating rules, the benefit mandate, all of those included in the Reid bill would not apply.

Wouldn't that make sense, I ask my colleague from South Dakota? What is the Senator's understanding of this and should not we be allowed to at least discuss and debate that as a Senate when we have been promised as citizens of this country that premiums would go down?

(Mrs. HAGAN assumed the Chair.)

I try to stay in close touch with the people of Wyoming. I go home every weekend. We have not been able to do that the last couple of weekends so I have had telephone townhall meetings. I know the Senator from Tennessee has done the same. There is a way people can push a button to indicate whether they are in favor or against. Ninety-three percent of the people of Wyoming are opposed to the bill the Democrats are trying to jam through in the middle of the night. I know the Senator from Tennessee has recently had telephone townhall meetings with his constituents because he was not able to be home personally with them. Maybe the Senator wants to share with us some of the experiences he has had and some of the messages he has heard from the fine folks of Tennessee.

Our friends at the University of Minnesota said that if people were allowed to shop across State lines, shop around for insurance that is better for them and their family and their personal situation, we would have 12 million more Americans insured today than we have now, without a single page of legislation. That is all we need to do: allow people to shop across State lines. But when we talk about and look at this bill, which has mandates, there is going to be a mandate for people to buy insurance.

One of the amendments I tried to offer yesterday that I thought made a lot of sense for young people was that for individuals under the age of 30 or for those making less than $30,000 a year, they would be exempted from the mandate, the individual mandate that they have to buy insurance.

I was involved in a discussion on a college campus in a debate on this topic, and in talking to the students, they were astonished to learn--because they were not focused on this; they were focused on their studies and working--they were astonished that they are all going to have to buy, as a matter of law, if this passes, health insurance immediately, and if they do not, they are going to have to start paying a tax or a fine, depending on how you describe it.

So in my amendment, I said, for those up to the age of 30 and making under $30,000 a year, let's exempt them from the mandate. That amendment was rejected.

Then I said, well, if they are going to do this and force these people to buy insurance, and if they do not buy insurance, they have to pay these excessive fines or taxes--or however you want to define it--I said, how about that the penalties these people would have to pay, if they choose not to buy insurance--because it is going to be a lot cheaper to not buy insurance and to just pay the tax--what if that money could go into a personal account so that person can then use the money to then buy insurance? So it would be kind of like a savings account, so the money would be there for them to buy insurance. So individual mandate penalties would accrue not to the government but in a personal account, so they could purchase health insurance within a 3- year period. The money would accumulate. That amendment was rejected as well.

So we have lots of ideas, good ideas, to help people with affordable care, available care, and yet one after another they have been rejected in a step-by-step process to try to find ways to solve the health care crisis we know faces the country. All 100 Members of the Senate know we need to find ways to make health care more affordable and to work on high-quality care.

It has been fascinating to see the dean of the Johns Hopkins Medical Center and the dean of Harvard and those who have looked at this bill closely say that the people who are supporting this are living in collective denial, that this bill is doomed to fail, that it will raise the cost of care, not lower the cost of care, and will do nothing to improve quality.

When you take a look at what the Centers for Medicare and Medicaid Services has done, which is the group that oversees Medicare, they have said that 10 years from now, if this goes through, you are still going to have 24 million uninsured, you are going to have 18 million more on Medicaid, the program the Senator from Tennessee appropriately referred to as having a bus ticket for a bus that is not going to come, because that is what has happened. Half the doctors in the country do not take care of patients on Medicaid because the reimbursement is so low that they cannot afford to continue to care for those people. Five million people will lose the insurance they get through work, and health care costs will go up. The cost curve will go up instead of going down. But the whole purpose of this was to help drive the cost down.

Then, additionally, they said that 20 percent of providers--20 percent of the providers--of health care in this country--and that includes physicians, nurse practitioners, medical clinics, hospitals-- 20 percent of the providers in this country, under this plan, 10 years from now, will be unprofitable, unable to keep their doors open.

So we have heard about sweetheart deals. We have heard about taxes going up. We have heard about Medicare cuts. And what we have seen is one promise after another made by the President that has been unfulfilled and actually reversed by the bill we see ahead of us.

So I ask my friend from Tennessee, wouldn't he agree that in the next 2 days, the best thing for the country would be to have this bill not pass the Senate and instead go back in a step-by-step way and regain the trust of the American people?

I thank the Senator from Wyoming and appreciate his leadership on this bill. It is of tremendous value to have within our body two practicing medical doctors to help us interpret the effect of this bill, which affects all 300 million Americans so dramatically.

We find, when we discuss this bill with our colleagues on the other side of the aisle, we sometimes become exasperated with one another because it seems like they are talking about one set of facts and we are talking about another set of facts. So what I would like to do is take a moment and talk about Medicare.

If anyone is watching our debate, you hear the Democrats talk about three things: We are saving Medicare, we are extending its length, and you hear Republicans say they are cutting Medicare. So who is right?

Well, let me tell you why we talk about Medicare cuts. Medicare, of course, is a government program which 40 million seniors depend on. We all pay into it, and then when we get to be of a certain age we depend upon it for our medical care. For many Americans, it is very important. It was established with broad bipartisan support in the 1960s.

What are the proposals that have to do with Medicare? Well, basically half this health care bill is paid for by reductions in the growth of Federal spending for Medicare. Those are Medicare cuts. Who says they are? Well, the President of the United States, for one, says we will have no deficit from this bill. So the way we are going to do that, for this bill, which the Congressional Budget Office figures show us will cost $2.5 trillion over 10 years when fully implemented, is basically paid for one-half by Medicare cuts and one-half by new taxes. Give the Democrats credit for that, that helps to avoid a large part of the deficit. The rest is done by sending a huge bill to States to help pay for another big government program called Medicaid, but I will leave that to the side for a moment.

The Medicare cuts which are reductions in the spending for Medicare, are $466 billion over the first 10 years and over a fully implemented 10 years it is about $1 trillion in Medicare cuts. That is money coming out of the Medicare Program and going somewhere. Where does it go? Well, it goes to start a new program.

What is wrong with that? Well, one thing wrong with it is the trustees of Medicare say that there is already more money coming out of Medicare than is being paid in, and by the year 2015 or 2017 it will be insolvent. That means going broke. These aren't Republican trustees or Democratic trustees, these are the men and women whose job it is to report to the Nation on the condition of this program that takes care of 40 million people and their medical care.

Already we see that the Medicare Program is under some stress. The doctors, for example, who serve Medicare are only paid about 83 or 84 percent as much as doctors who serve patients with private health care. As a result of that, we have to come along year after year and appropriate more money to reimburse doctors who serve Medicare patients. If we do not do that, they will not be serving Medicare patients, and Medicare will become similar to Medicaid, the program for low-income Americans, where about 50 percent of doctors will not take a new Medicaid patient. It is akin to telling somebody: I am going to give you a ticket to a bus line where the bus only runs about half the time.

So what the Democrats are saying to us is that by taking $1 trillion out of Medicare over 10 years when fully implemented, and there is no dispute about that amount of money, and spending it to pay for this new program that is somehow good for Medicare and for the seniors who depend upon it. I mean, they are suggesting we believe if you take $135 billion from hospitals and $120 billion from the 11 million seniors who participate in Medicare Advantage and $15 billion from nursing homes and $40 billion from home health agencies and $7 billion from hospices, that somehow that is good for seniors.

Perhaps it could be, if all that money were put back into Medicare; if the money were taken from grandma and spent on grandma. But no, this money is taken out and spent on a new program. The Director of the Congressional Budget Office--not a Republican, not a Democrat, the nonpartisan Director said, for the 11 million on Medicare Advantage that one-half of their benefits will be diminished. That is what he said about these cuts.

Even when it is all said and done, we completely leave out the $\1/4\ trillion that we need to appropriate to pay the physicians to serve Medicare patients. Because if we don't, their payments are going to be cut by 21 percent next year and fewer of them will see Medicare patients. We have already heard the Mayo Clinic, for example, is beginning to restrict some patients on Medicare because they lost $840 million serving Medicare patients last year.

I have taken a few moments to talk about Medicare. That is just one thing wrong with this bill. But when you hear the other side say they are helping Medicare, and if you listen to what I said about how can you take $1 trillion out of the Medicare Program--which is going broke--when it is fully implemented over 10 years and claim you are helping Medicare by starting a new program, I don't think that is possible. That is the source of the great concern on our side of the aisle about this bill on that one issue.

I see the assistant Republican leader, the whip. I have heard a number of people say, and I will just propound this question and then I will yield the floor, if I may, to the Senator from Arizona. But I have heard them say: Why are Republicans keeping everybody in here this week? We want to go home and see our families.

We all want to see our families. But there is a reason this bill was suddenly presented to us in the middle of the greatest snowstorm in the history of Washington in the month of December, and we were asked to start voting on it in the middle of the night on the same day, and to finish the work by Christmas. If I am not mistaken, and this is my question to the distinguished assistant Republican leader who has been here a number of years, who is in the leadership and whose job is to help manage the floor: Is it not entirely the prerogative of the majority leader of the Senate to schedule what comes up on the floor? Is that not his job? Isn't it true that if Senator Reid wanted to say let's take this bill down, let's go home, let's let the people hear about it, let's come back and vote on it after Christmas, after New Year, after Valentine's Day, could he not do that and

isn't that peculiarly his power and not our power?

No, I thank the Senator. I yield the floor.

Mr. President, I agree with the Senator from Wyoming. I think it is important for the American people to know, the 400-page amendment that was added to the underlying bill over the weekend is being presented to us in way that will not allow the bill to be amended. So something that affects one-sixth of the economy, which we have had a day and a half to read, which is part of an overall bill that will raise taxes, cut Medicare, and send big bills to States could be improved with amendments but cannot be amended under the current procedure.

Madam President, the telephone townhalls are interesting. This is the 21st consecutive day and the third weekend we have been debating this bill. One would think we could probably do a better job of it, if we were going back home every weekend to hear what people thought about what we were doing. But maybe the strategy has been to keep us here talking to each other, bring the bill up in a snowstorm, pass it in the middle of the night and go home for Christmas, and the people won't find out what we are doing until it is too late. One way to find out is tele-townhalls. I was skeptical before I did one but it is a pretty interesting way to stay in touch with people from Tennessee. You get on the telephone and an automated system calls thousands of people and says: The Senator from Wyoming or Illinois or North Carolina or Tennessee wants to talk with you about health care. People can either stay on the phone when they get the call or they can hang up. What normally happens is a person stays on the call, this time a surprisingly large number of people stayed on the call, because of their strong interest in this issue.

The other night I did the phone call between 7:30 and 8:30. I called to about 18 west Tennessee counties, including Shelby, which is Memphis, and as reported to me by the service, about 30,000 people were on the telephone sometime during that hour, with a maximum number of 3,016 on the call at any one time. Someone might pick up the phone and say: Senator Barrasso is on the phone. They might tune in for 15 or 20 minutes and then hang up. Maybe they have to cook dinner or the ball game comes on. Maybe they get tired of talking to you, but they are on for 15 or 20 minutes. During that time, I was able to take a number of questions. After it was over, 563 messages from constituents were sent to my Web site.

It was interesting to me. People who know my history, know that to be elected Governor 30 years ago, I walked across the State of Tennessee. Instead of going to a Republican meeting or a rotary club, I would visit with random people during my walk. It took me 6 months and I would see 1,000 people a day. These random phone calls kind of reminded me of that. It was as if the people were randomly selected. They were not on any Republican list or Democratic list or list of doctors or patients. They were just in the phonebook. They talked and acted like they were normal citizens who I had interrupted after dinner, probably because it was 6:30 to 7:30 in that part of Tennessee. I was able to ask those citizens three questions. I am not about to say this is a Gallup poll of Tennessee, because I know that surveys like that have to be done in a scientific way, but after being here for 21 straight days, not able to go home because we have been debating this bill, these opinions are straws in the wind.

The first question was: Do you believe the Senate should rush to pass this health care bill before Christmas? In this case, 943 people, 83 percent, said no, and 108 said yes; that is 9 percent.

Second question: Do you support the health care bill moving through the Senate? On this one, 1,496 said no, or 75 percent. 352 said I don't know, which is 18 percent, and 154 said yes, that is 8 percent.

No. 3: Do you agree that Congress doesn't do comprehensive legislation well and ought to go step by step to bring health care costs under control? On this question, 1,285 said yes, that is 80 percent, 14 percent said I don't know and 7 percent disagreed.

I have often heard our friends on the other side say: Where is the Republican bill? My response has been, day after day, if you are looking forward to seeing the Republican leader role a wheelbarrow in here with a 2,700-page Republican comprehensive bill, you will be waiting forever. We have a different approach. Our approach is to set a clear goal--reducing cost. The bill we are voting on increases costs. Our goal is to find five or six steps to go in the direction to reducing costs.

Without going into detail, although the Senators from South Dakota or Wyoming may want to, we focus on five or six steps that would clearly reduce health care costs. By that, I mean your premium, the cost of your government. And once we do those five or six steps, we could go on. We could do that without taxes, without mandates, without running up the debt, without a big bill with lots of surprises. Just to take one example--and then I will yield to my friends from Wyoming and South Dakota--one of those examples is the small business health care plan. The current bill, the Democratic bill, has in it a credit for small businesses, but we would argue that by the time small business men and women get through paying the mandates and the taxes the bill also imposes, it is not going to be much help to them.

What we have is a bill that would allow small businesses to pool their resources. In other words, if you are a small business man or woman and you have 60 employees and 2 get cancer, suddenly the costs of those 2 employees prohibit you from providing insurance to the other employees. But if you could pool your resources with small businesses all around the country, then the pool would be large enough that you could offer insurance.

That proposal has been made by Senator Enzi. It has been through the HELP Committee. The Congressional Budget Office said it did not add to the deficit. In fact, it reduces the deficit, and it would permit 750,000 more employees of small businesses to be insured and their premiums would be lower than they otherwise would be. That is a single step to moving toward reducing health care costs, but if we took that step and the other steps we have proposed, that would be a good way to start. We could do that together, and we would not have this partisan bill with so many questions and so many concerns.

So I wonder if my friends from South Dakota and Wyoming--I know they have thought a good deal about this step-by-step approach toward actually solving the real problem of health care costs.

It clearly does. It enjoys widespread support everywhere, except the Senate. When Senator Enzi brought it up, it was rejected by our friends on the other side.

I thank the Senator from South Dakota. The answer is no. The difficulty with a big, comprehensive plan is it sounds good but has lots of unintended consequences. If our real concern right now is reducing costs in health care, then the idea of a small business health care plan that has no new taxes and no new mandates but creates opportunities for small businesses to pool their resources and offer more insurance at a lower cost to their employees would seem a logical place to start.

I certainly do agree with that.

I think most Americans, when presented with a problem, would not try to change it all at once but would say: Let's identify the goal which is reducing costs and go step by step.

Madam President, I ask unanimous consent to have printed in the Record a column by David Brooks in the New York Times on December 18.

Most of us--we are pretty split up here: 60 there, 40 here. They are for it, and we are against it, this bill anyway.

I thank the Presiding Officer and I yield the floor.

Madam President, I rise to declare and explain my support for the Patient Protection and Affordable Care Act. First, I commend Senator Reid and all those who worked so long and hard, including my friend and colleague from Connecticut, Senator Dodd, for all they have achieved in this legislation. The truth is, no piece of legislation, as significant and complicated as this is, could possibly be totally satisfying to every one of us. In the end, each one of us has to ask ourselves: Do the positives in this legislation substantially outweigh the negatives? Are the things we like in the bill greater than the things that worry us? For me, the answer to both these questions is yes, because this bill makes real progress on the three important goals I have had, and I think most people have had, for health care reform.

First, most of us have wanted to stop the continuous increases in the cost of health care that burden every individual, family, business, our Government, and our economy. Second, we have wanted to regulate insurance companies to provide better protections for consumers and patients. Third, we have wanted to find a way to make it easier for millions of Americans who cannot afford health insurance today to be able to buy it tomorrow. I believe this bill makes real progress in achieving each of these three goals. Most importantly, it does so in a fiscally responsible way.

The Patient Protection and Affordable Care Act not only does not add to our national debt, through new health care delivery reforms it will help reduce the debt by $130 billion over the first 10 years, according to the independent Congressional Budget Office. That figure could multiply many times over during the second 10 years, thanks, in part, to the managers' amendment that incorporated stronger cost-containment proposals that several of us, across party lines, made to Senator Reid.

In addition, it is very significant that, according to the Actuary at the Center for Medicare & Medicaid Services, this bill will extend the solvency of the Medicare trust fund for an additional 9 years. This act will also take substantial steps toward creating a health care delivery system that pays for the quality of the care patients receive rather than the quantity of care. I am proud to have worked with Members of both sides of the aisle to include amendments that would do that.

For instance, Senator Collins and I introduced an amendment, parts of which were included in the managers' package, that will enhance transparency for consumers so they can make more informed decisions in choosing their health care providers and insurers. In fact, our amendment will create Physician Compare, a new Web site where physician quality measures that exist now but are not known by the rest of us will be posted for everyone to see and to use in the choice of physicians. This will also create incentives, we believe, for doctors to provide high-quality, more efficient care.

I also cosponsored an amendment introduced by Senator Warner and some other freshman Senators that will contain costs even more. This amendment creates prevention programs to help us understand how to effectively manage chronic diseases such as diabetes, and it requires prescription drug plans under Medicare Part D to offer medication therapy management services to beneficiaries so they can better adhere to their prescription treatments. All that is progress on the first goal that I and most others had, which is to reduce the cost of health care without compromising--in fact, improving--its quality.

The second goal. If this bill passes, insurance companies, as Senator Kerry said, will not only not be able to deny coverage if an individual has a preexisting condition, they will not be allowed to rescind coverage if you become sick, which is the outrageous reality today. Thanks to changes made by the managers' amendment, insurance companies will also be required to spend more of the premiums they collect on medical expenses for patients rather than on administrative costs and profits. That is real progress on the second goal I mentioned.

As for the third goal, the fact is attested to by the CMS Actuary and CBO, 31 million more Americans will be able to have health insurance as a result of this legislation. We say that so often I think we forget the power of it--31 million people who do not have health insurance today will have it after this bill passes. That is a giant step forward for our society. It is not only the right thing to do, but it will also eliminate the so-called hidden tax that each of us who has health insurance today pays in higher premiums when someone who has no health insurance gets sick and goes to the hospital to be treated. That is real progress on the third fundamental goal of health care reform that I mentioned.

Is there anything in the bill that worries me? Of course, there is. I would say, most of all, I worry that we, and future Congresses, will not have the discipline to keep many of the promises we have made in this bill to control costs by transforming the way health care is delivered because some of these reforms are controversial and they are going to be opposed by some health care providers and health care beneficiaries. Without the kind of discipline I have just mentioned, this bill will add to our national debt or increase taxes. Neither of those results is acceptable. If we stick to the contents of the bill, this bill will cut health care costs and it will reduce our national debt.

In my opinion, our exploding national debt is the biggest domestic threat to our country's future. That is why I have said this bill must reduce that debt, not increase it. Accumulated debt is currently over $12 trillion, with our budget office estimating an additional $9 trillion added in the next 10 years. That is unprecedented in our history. We are running up to the time when we can see a moment possible that we never thought would be possible, when our capacity as a nation to borrow will be imperiled, when we will have to raise interest rates so high it will constrict our economy and send us back into a recession, worse than the one we are coming out of now.

We cannot bring the fiscal books of our Government back into balance by only making the health care system more cost efficient, but we will never control our national debt without doing so. Medicare is in a particularly perilous condition today. Without reform, the Medicare trust fund will be broke in 8 years--broke. With tens of

millions of baby boomers reaching the age of eligibility, we simply must protect Medicare so it remains a viable program for both current and future generations.

This leads me to my firm opposition to the creation of a new government-run insurance program and to lowering the age of eligibility for Medicare to 55 years. That opposition was rooted in my very serious concerns about our long-term national debt and the fragile fiscal condition of Medicare. For any new government-run insurance program, including the Medicare extension-expansion idea, the moment premiums do not cover costs the Federal Government--that is Federal taxpayers, the American people--would have to pay the difference. That could easily put our Federal Government and the taxpayers on the hook for billions and billions of dollars in future liabilities and further jeopardize the solvency of Medicare.

Because of the insurance market reforms in this bill and other measures--the creation of a new system of tax credits and subsidies for people making up to 400 percent of poverty--the creation of a new government-run health care, the so-called public option or the expansion of Medicare to people under 65 is not necessary. Neither proposal would extend coverage to one person who will not be benefited by the new provisions of this bill, neither the public option nor the expansion of Medicare. Yet both proposals would, in my opinion, lead to higher premiums for the 180 million people who have insurance today and are struggling to afford the health insurance they have now because of cost shifting.

According to studies by the CBO, a new government-run insurance program, a public option, would actually likely charge higher premiums than competing private plans on the exchange, and expanding Medicare to cover people 55 years or older would lead to additional cost shifting.

I know the removal of the public option from the bill in the Senate disappointed and angered many Members of the Senate and the House, while I know it pleased and reassured others. I wish to say to those who were not happy about the removal of the public option from this bill that I believe President Obama never said a public option was essential to the reform goals he set out to achieve and that most of us have. When the President spoke earlier this year to the Joint Session of Congress, he said a public option is ``an additional step we can take.'' An additional step, he said, but not an essential one. Then, he added, ``The public option is only a means to that end.'' He concluded that we should remain ``open to other ideas that accomplish our ultimate goal.''

I am confident this bill accomplishes the goal the President and most of us set out to achieve without the creation of a brand-new government-run insurance company or the further weakening of Medicare. This bill, as it appears it will emerge from the Senate, is delicately balanced. I understand the normal inclination in a conference committee with our colleagues in the House is to split the difference. But splitting the difference on this bill runs a real risk of breaking the fragile 60-vote Senate consensus we have now and preventing us from adopting health care reform in this Congress.

That would be a very sad ending. Rather than splitting our differences, I hope the conferees will adopt our agreements so we can enact health care reform this year. The rules of the Senate require 60 votes to end debate on a conference report.

I ask unanimous consent for an additional moment, maybe 2 moments, to complete my remarks.

Each Member of the Senate will have to decide once again when this bill emerges from the conference whether he or she wants to be one of the 60 votes necessary to take up and pass the conference report. In this case my own sense of the Senate is the same as that expressed in the last few days by Senators Conrad, Nelson, and others. If significant changes are made to the Senate bill in conference, it will be difficult to hold the 60 votes we now have. I have two priorities that will matter a lot to me. The first is to continue and maintain the health care reforms that will improve the cost-effectiveness of our health care system and help reduce the national debt. Second, I hope there will be no attempt to reinsert a so-called public option in any form in the conference report. That would mean I will not be able to support the report.

I want to support it. I believe I am not alone in that opinion among the 60 who supported the bill last night. Our exploding national debt is the biggest threat to our Nation's future. That means we must begin to make politically difficult decisions to reduce our debt. That means saying no to some groups and some ideas, including some we would otherwise support, because we simply cannot afford them.

A final hope about the conference report. Perhaps some will say it is naive. I hope the conferees will find a way to produce a report that can be supported by some Republican Members of the Senate and House. It is a sad commentary on this moment in our political history that so major a reform will be adopted with no bipartisan support. Hopefully the conference will find a way, difficult as I know it might be, to conclude this long legislative journey with a bill that is not only worth supporting, as I believe the Senate bill now surely is, but also engages the support of Members of both parties.

I yield the floor.

I ask unanimous consent to yield myself 10 minutes.

Mr. President, late last night, as my colleagues are aware, the Senate took the important step to move forward on health care reform. After all the work, the debate that has gone on for this entire year, we owe the American people a vote on this issue. We can't afford to ignore this situation anymore.

I know some of my colleagues on the other side of the aisle have been talking about a lack of debate. I think anyone who has turned on C-SPAN for the last few months will tell you there has been a lot of debate-- not only that, a number of Republican amendments were actually included in the original bill, the HELP Committee bill. When it came out, I believe it was something like 130 amendments that were included that came from their side--and the Finance Committee as well.

I remember the first bipartisan meeting we had on health care reform was something called Ready to Launch that the Finance Committee put together. I remember Senator Whitehouse and I were there. It was literally a year and a half ago. So many of the ideas that are now incorporated in this bill that Senator Bennet from Colorado just so eloquently went through are in this bill, so many of the bipartisan ideas to kick off cost reform, to start rewarding high-quality care, to start bringing down those costs in a way that gives us the high-quality care.

We all know that rising costs are not sustainable. If we don't act, these costs are going to continue to skyrocket.

So what was the vote about last night? The vote last night was to say we are not going to put our heads in the sand anymore. We are not going to keep letting these costs go up.

Ten years ago, the average family was paying $6,000 a year for their health insurance. Now they are paying $12,000 a year. Well, 10 years from now, if we don't do anything about this, they are going to be paying $24,000 to $36,000 a year for their health insurance. Just look at these numbers. Look at where we are. In 1999, a single person was paying about $2,100 for their health care. They were paying for a family, $5,790 for their health care. Where are we now? Last year, in 2008, a single person was paying $4,700 for their health care and then a family was paying $12,680. Especially during this difficult economic time when wages haven't been going up, people have been losing their jobs, cutting back on their hours, and look what their health care costs have been. It has been a higher and higher percentage of their family budget, a higher and higher percentage.

At the same time, health care expenditures are going up and up and up. In 1995, we were spending something like $12 billion and now it is way up to $2.5 trillion. This is the kind of money we are talking about when we look at why we have to do something to bend the cost curve. When people at home hear this term ``cost curve'' and they don't know what it means--well, this is exactly what it is: The cost curve has been going up and up and up for health care in America.

So $1 out of every $6 spent in our economy is on health care. Over 20 percent of our economy, by 2018, we believe, will be spent on health care. American families can no longer afford it.

Who has been taking it the worst? Small businesses. They are paying 20 percent more than large businesses for their health care. In a recent survey, nearly three-quarters of small businesses that did not offer benefits cited high premiums as the reason.

These are little companies such as Granite Gear up in northern Minnesota and Two Harbors. I went up there and visited them. They are a thriving little company. They now have 15 employees. They are making backpacks for our Nation's soldiers because they make such high-quality backpacks. Do you know what the man who started that company told me? That if he had known how much his health care would cost with his family of four--he did not have kids when he started the business--he would not have started it today. He is paying $24,000 in Two Harbors, MN, for a family of four.

This is what it really means when you look at the numbers. Inflation usually raises the cost of most goods and services between 2 and 3 percent a year. What have health care premiums been doing? Health care premiums have been going up close to 8 percent a year, and that is an increase Americans simply cannot afford.

What does this bill do? I was listening to some of the commentary and taking part in it myself over the weekend. There seems to have been a lot of talk about these delayed benefits. Why don't we talk about the benefits that are taking place right when the President signs this bill, within the first year of this bill?

The first thing is, if your kid loses their coverage because something goes wrong--if they get diabetes or if they have some childhood disease--guess what. They are going to be able to get health care. There is no longer a ban on preexisting conditions immediately, and then in later years that applies for adults as well but immediately for kids.

Immediately, by 2011, within the first year of the bill, our seniors are going to be covered in that doughnut hole for their prescription drugs. So many of them for so long--I know my own mother would complain about this doughnut hole where they fall off a cliff and are not able to pay for their drugs because they do not have enough money. That will be covered.

A number of the small business tax credits take effect by 2011. These are real benefits for the people of this country--real benefits.

The thing I care most about in this bill which Senator Bennet discussed is this idea of getting our money's worth for our health care dollars. What does this bill do? This new bill--we have taken a lot of the good from the original bill and made things even better: $132 billion off the deficit in the first 10 years and in the next 10 years, $1.3 trillion off the deficit. That was the most important thing to people in my State when I went around. They said: We want to get rid of these preexisting conditions, we want to make things better so we have better health care, but we want to make sure we do something about the deficit, start doing something about costs.

As you know, Mr. President, Minnesota is a mecca for health care. We have one of the high-quality, cost-efficient, low-cost States in the country. In fact, when we look at some of the numbers, one of my favorite ones--and

maybe this will be the last time I will say this before the end of the year--is Mayo Clinic. They did a study out of Dartmouth, and they looked at what Mayo did with chronically ill patients. What they found was this: If other hospitals in the country simply use the same high- quality care Mayo uses--bring the family in, talk to them about what the care should be for the patient--they talk to the patient and then figure out what is the best course. They work as a team, like a quarterback with a team working with that quarterback. They do not have 20 specialists falling all over each other; they work as a team. What this study showed was this kind of health care for that subset of chronically ill patients in the last 4 years of their lives, the quality ratings were sky high for the Mayo Clinic. The families felt good about how their loved ones were treated.

What Dartmouth found is if all the hospitals in the country followed the same protocol, we would save, for this subset alone, $50 billion every 5 years in taxpayer money, giving patients that Mayo health care, giving them high-quality health care. It is counterintuitive to people. If you go to a hotel and you pay the most, you are going to get the best room with the best view. That has not been the same in American health care. In fact, there is an inverse relationship.

I see my friend from Ohio. Ohio has the Cleveland Clinic, and there is Geisinger. Those places that offer high-quality care also tend to have some of the lowest costs.

Those are the incentives we are putting in this bill--incentives for accountable care organizations, incentives for that integrated care I talked about instead of people running around with x rays to 20 specialists, getting charged every single time, but then one specialist does not know what the other specialist is doing. They don't know what kind of drugs you are allergic to when you go in for surgery. This is because there is no communication. This bill promotes that integrated care where you put the patient in the driver's seat so they have their pick of a doctor. That is what we want--bundling of payment so you start rewarding outcomes instead of the number of tests and procedures.

My favorite example of this came out of the Geisinger Clinic in Pennsylvania, where they said: We are not that happy with how we are treating diabetes patients. So instead of having everyone wait to see an endocrinologist, a doctor, we are going to have some of the routine cases see nurses, and the nurses will report to the doctors, and the patients will be happier because they will be able to see a nurse more often. The most difficult cases will be treated by endocrinologists.

They did that for about a year and looked to see what the results were. Guess what. The patients were much happier because they were able to communicate one-on-one with the nurse. The doctors were able to handle the most difficult cases and monitor the other cases. They saved $200 a month per patient with this kind of system. Higher quality care and better patient outcomes.

What does our system do when they see this kind of smart, cost- effective result for the doctors and for the system and for the taxpayers? They actually are told: You get punished for this under our system. You are going to get a lot less money if you do something like this. That is what I am talking about.

On hospital readmissions, we could save $18 billion a year. If you go in the hospital and you are treated, you want to go home. You don't want to go back into the hospital because someone made a mistake or they gave you an infection. Let's provide incentives--that is what this bill does--so that we reduce those hospital readmissions, make life better for the patient and at the same time reduce taxpayer money. That is what this bill is about.

Right now, fraud is $60 billion. I don't think anyone would believe this. A senior who just depends on Medicare, right--we have to tell our seniors today that $60 billion a year is wasted on Medicare fraud, going to con men, going to people who set up storefronts and they get fake checks and they are not even real. That is where the money is going right now--down the tube, siphoned off by fraudsters. What this bill does is give the tools to improve that situation so that will not happen anymore.

That is what we are doing with this bill. It is about reducing costs, it is about raising quality, and it is about saving Medicare so it does not go in the red by 2017, giving it 10 more years and beyond because of the delivery system changes.

I am proud to support this bill. We continue to work for reform. As you know, this is not just an end, this is a beginning. There will be more work to do in the future, but we cannot put our heads in the sand. We have to vote on this bill. We have to get this done.

I yield the floor.

Madam President, I have a question for both the Senator from North Carolina and the Senator from Nevada. Can the State of Nevada or the State of North Carolina or the State of Nebraska or the State of Oklahoma be healthy if our country doesn't flourish? So no matter what we do for our own States, if, in fact, we are not thinking about the country as a whole, the best right thing for the country as a whole, none of our States can flourish.

Madam President, I ask unanimous consent to have printed in the Record an article that appeared today. It is a quotation from the founder from the Daily Kos Web site. I will give it to the clerk in a moment. I wish to read a quote from it:

I don't think this is a reform bill. I mean, I think it is

very clear this is not insurance or health care reform. What

it is is allowing more people, 30 million people, to buy into

an existing broken system. It is very important to keep in

mind that health insurance is not the same as health care. If

you go up to Massachusetts, they have a mandate as well. Last

year, in Massachusetts, 21 percent of the people who are

insured could not get health care because they could not

afford it.

That is somebody who is very well respected on the majority side, and it is something we have been saying, and they are saying the same thing. The fact is, what we are going to do is put 15 million people into Medicaid that we know has worse outcomes, we know is an unfunded mandate on the States, and we know 40 percent of the doctors refuse to see them. So you are not going to get to choose the doctor you want to see. You are going to have State mandates in terms of what is available to you and what is not. So we have violated two of the key promises with which to reform health care.

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

He quotes very directly the transfer. He said a previous article written:

. . . doesn't emphasize a potential stealth cost-control

aspect proposed in the bill. It will start pilot programs

that would transfer the gatekeeper role to doctors at the

bedside, a role currently held by ``payers'' (HMOs and

government-agency insurers, including Medicare and Medicaid).

The transfer will be via capitation fee payments, making

clinics ``responsible'' for the cost of care of ``insured

lives'' for one year. . . . The illusion of many pundits and

policy makers is that mini provider gatekeepers can control

costs after the very powerful payer gatekeepers--

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

have failed for decades. The problem for patients is the

dilemma of all managed-care gatekeepers: cost, quality,

access; pick any two. It is not pleasant to think that one's

gatekeeper doctor will have to decide whether to order

surgery for your painful [worn out] hip or only to increase

the dose of--

Anti-inflammatories because they are worried about costs.

That is the key point. We are going to now separate physicians in this country for doing what is best for the patient to meet the demands of the government.

I will be happy to yield.

That is exactly why I am not a member of any HMOs.

Let me finish this for a minute, if I might. Here is the summarizing paragraph:

The economic reality is that no rationing of care supply

will ever control costs, when the problem is demand inflation

driven by popular insurance tax subsidies too sacred to

repeal. Consider that when federal fiscal ``necessity''

overwhelms empty slogans,--

Our empty slogans--

scores of new bureaucracies created in [this bill] would be

able to implement Draconian rationing in collusion with

subservient insurance and ``provider'' corporations. The high

costs, as well as the rationing powers included in the more

than 2,000 pages of the ObamaCare Senate legislation are very

real.

Which is the point I have been making all along. I am going to spend 30 minutes tomorrow talking about the rationing aspects of what we are about to do as we pass this bill.

What we also know from the Congressional Budget Office is that between 9 and 10 million people who today have insurance through their employer will actually lose it. They are going to lose their insurance. That may be good or bad for them. But if you look at the incentives, the subsidy for people who do not get insurance through their employer, if you make $42,000 a year, today with your health insurance through your employer you get a benefit of about $5,749 from the tax system. But under this bill, you will be eligible for $12,500 worth of subsidy.

What do you think an employer is going to do? They are going to look at their employees and they are going to say: I have to pay this penalty if I don't offer this, but it is a significantly smaller amount than what I am paying today. Therefore, I am going to make a decision to no longer offer health insurance, give my employees a small raise because the government is going to come in with $12,500 worth of subsidies to put them in a ``private'' plan inside the parameters of what is in the exchange. How many people do you think it is going to shift?

What we are going to get is adverse selection. So the individual-- let's say I am working and I am making $42,000 a year and my employer decides to do that and let's say I am 35 years old and I know available to me is $12,500. Even though my earnings may go up, I am still 2\1/2\ times better off.

I also know I will have to pay $3,000 or $4,000 of my own money to get that benefit. I will not cover myself because I know I can cover my little incidentals. If I get sick, they have to cover me in the exchange.

So we are going to see adverse selection in the insurance market, people who are between 40 and 64 who are sick are going to pay far more for their health insurance and people who are sick who are younger than 40 are going to pay far more for their health insurance and everybody who is healthy under 40 is going to say: This is an economic bonanza for me. I am not going to buy insurance.

Well, the disappointing thing--and I have worked on this for 5 years, since I have been here--is we are not honest with the American people about how we account for things, and this bill is another example of that. Let me give you the quantifications.

If you read the CBO report on this bill, they talk about it is highly unlikely we will ever actually make the Medicare cuts, because they have never seen it done, and every time we have said it in the past, we haven't done it, like the sustainable growth rate formula in the Balanced Budget Act of 1997. So if you match up revenues and expenses, what you see is a $1 trillion tax increase, a $1 trillion cut in Medicare, and an increasing cost to the economy.

But because there is not the sustainable growth rate--the doctor fix in the bill--that is $247 billion not accounted for, and that is if you keep physician wages frozen over the next 10 years. That is $247 billion, probably closer to $300 billion. So that is $300 billion. The fact is we know the taxes that are going to be collected, people are going to pull down the cost, which is one of their hopes, and they are going to pay for it out of their pocket.

So we are going to see that insurance plans not reach the Cadillac level, and we are counting on revenues from that in terms of billions and billions and billions of dollars. But what they will do is change the deductibles--and that is a hidden tax. Because if your deductible goes up to keep your insurance from going too high, your tax goes up in actual expenditures. So your ability to invest and create additional jobs--in other words, it cascades. The honest accounting for this is that there is no way this saves any money. It will cost money.

The final point I will make is they won't put forward the cuts in Medicare that they are claiming in this bill. Because they know if they truly do put forth the cuts, and patients feel it, they won't be back here. So it won't happen.

I will go back to what Senator Burr started this out with. If you are going to start tomorrow and fix health care, what would you do? You would attack costs. Why are things so costly? One is because there is no transparency in markets. There is no real connectedness to your pocket. No. 3, there is no incentive for prevention of chronic disease or the management of it. In other words, we don't pay people to have less expensive outcomes. We won't incentivize better care in that way. We won't incentivize prevention.

We have done a lot of this on Medicare--and I will talk about it tomorrow--but they have three different agencies within this bill that are going to ration care. They are going to make the decisions for you, and not just on Medicare and Medicaid. Everybody needs to understand that. It doesn't just apply to Medicare and Medicaid, it applies to your choice of your private insurance. The government is going to ration your care.

We know that is true because they wouldn't allow an amendment to prohibit rationing. They all voted against the amendments in committees when we offered amendments to limit rationing. So we know the intention is to ration care. If that is how we are going to control costs, then Bernie Sanders is right--go to a single-payer, government-run system. Bernie Sanders' system is far better than this one--far better than this one--if that is what we

are going to do. If we are going to ration care, let everybody know it upfront. Let's be absolutely honest about it.

If you are 75 years of age and need a hip replacement but the quality of your life is not all that great, we are going to say you can't have it. That is what we are going to do, because that is exactly what they do in England. They have the National Institute of Comparative Effectiveness which makes an evaluation of what your worth is. And no matter what your history, no matter what your family situation, no matter your income, you can't have it.

Canada is getting around that, because they have said you get the right to buy what you want. Their Supreme Court ruled on that 2\1/2\ years ago. So we are seeing a two-tiered system developing in Canada, which ultimately will happen in this country--worse than what we have today.

They will go to Thailand or India.

I thank the Senator for holding this colloquy, and I will make one final point before I stop.

I don't doubt the motivation of our colleagues on the other side of the aisle. They want us to fix this problem--the problem in health care. But the problem is cost. If you don't fix cost, and you expand the same broken system, you haven't fixed anything. You have added to the cost.