Health Care Fraud Enforcement Act of 2009

I ask unanimous consent that the order for the quorum call be rescinded.

I rise today to join my distinguished colleague from New York, Senator Schumer, to express my strong support for extending unemployment benefits for workers around this country who continue their struggle to find jobs in this weak economy.

The problem is especially acute in my home State of Rhode Island, but this is a national problem, and it is creating significant unhappiness, significant distress, and significant woe in families all around the country as they approach the end of their unemployment benefits and cannot find a job. And the end is coming up for so many people. We really need to do something about it.

Right now, we are on a motion to proceed to the Unemployment Compensation Extension Act of 2009. We are not actually on the bill yet because our colleagues on the other side of the aisle are using every available form of procedural delay. It is not hard to figure out why they are doing it. There are only so many days in the year. There are only so many days the Senate can be in session. And when they force these votes and when they force delays, what they are doing is burning the work time of the Senate. They would like to burn the work time of the Senate because that inhibits the President, that inhibits us, it inhibits progress, and that presently is their motivation. They are the party of no. And because they do not have the votes for a lot of this stuff, until they can get to it, they are the party of slow. And we have had innumerable--I think the record right now is that we are at 82 efforts--to filibuster or force the majority leader to file cloture. We have had votes forced on judges. Some of the judges went through with huge margins by the time the vote actually came, but they wanted to burn the time. Indeed, as the Presiding Officer, the distinguished Senator from Illinois, may recall, the other day we voted on a judge, and the vote was 100 to 0. Yet they had to force a vote. Why? To burn the time of the Senate to prevent progress.

This should be one bill where they would stand down from their mission to be the party of no and the party of slow. Because since October 8--when they first put up the procedural obstacles to this bill--to now, 7,000 Americans a day have lost their coverage. They have come to the end of their unemployment coverage. It has expired, and they have lost their incomes.

As the Senator from Illinois, the distinguished Presiding Officer, so distinctly knows, there are millions and millions of families in this country who live paycheck to paycheck and when they lose their jobs, they live unemployment check to unemployment check while they desperately seek work to feed their families and put a roof over their heads.

This bill--if we could get to it, and if we could vote on it--would provide a badly needed lifeline to those Americans, and I would hope at some point our Republican colleagues would relent and simply let us make this decision, which is in everyone's best interest. It is inhumane, frankly, to put those families--7,000 a day--through the torment of coming to the end of their income and having to think about losing their houses, losing their cars, not paying for their prescriptions, not paying for their food, worrying about their children--all of that. That is an awfully high price to score political points on this floor and to be the party of slow and the party of no. I would hope their point of view will change.

I want to, first, applaud the efforts of my senior Senator from Rhode Island, Jack Reed. He has long been a champion of helping the unemployed, and he has played a critical role in getting this legislation to the floor for the Senate's consideration. Notwithstanding the fact that our Republican colleagues are interfering with allowing us to pass this legislation, Senator Reed's leadership on this issue has been remarkable, has been commendable, and we in Rhode Island are fortunate to have his service.

One of the reasons Senator Reed is so concerned about this is because our home State--the State of Rhode Island--has the third highest unemployment rate in the Nation. We broke 13 percent last month. That is the highest level Rhode Island has seen for unemployment since World War II.

According to the Bureau of Labor Statistics, over 74,000 Rhode Islanders are currently looking for work. There are 74,000 families with a wage earner out of work in a State with just over 1 million people. At that level, there are very few Rhode Islanders who are not touched in some way by our unemployment crisis.

Families are struggling through this recession in every State, but the situation is particularly dire in States such as Rhode Island, Michigan, and Nevada where the unemployment level has hit double digits and is climbing still. People who have worked their entire lives have been unable to find work this year. The economies of the worst hit States are getting worse, and the unemployment benefits continue to run out.

I have heard from hundreds of constituents who fear they will be unable to keep their families fed or keep the electricity on or keep up with their prescription drugs when their unemployment benefits expire. My State is in economic crisis, and we need help.

One of my constituents, Carole, from Centerdale has degrees in architecture and business, but she has been unable to find work for 18 months. She has two children. They are 12 and 15. Her unemployment benefits have run out. Without more help, she may lose her home.

I send out my good wishes to Carole and my thoughts to her for a complete recovery. She has recently suffered a heart attack. She is recovering nicely,

and I wish her well in her health. But we could do a lot for her if we could clear this bill so she did not have to look at her 12-year-old and her 15-year-old and, in this market, say: I don't know where our income is coming from now because this government cut off the unemployment benefits.

Another constituent is Patricia. She is a 51-year-old woman from Warwick. She has been unemployed for 17 months. She spends over $300 a month for her prescriptions, and she can no longer afford to keep up the COBRA payments that will protect her if she gets seriously ill. Without assistance, she may need to go into bankruptcy.

I tell just these two stories, although there are thousands more from those 74,000 Rhode Island families, because the statistics are sobering--13 percent unemployment, the highest level since World War II. That is a deeply distressing statistic. But behind those statistics are these personal stories, over and over again, thousands of examples of human suffering, human courage, that we must not ignore as we quarrel over irrelevant amendments and do not get to the business of helping these people in their hour of need.

I am pleased that in addition to the 14 weeks of benefits this legislation would provide to unemployed workers in all States, workers in States with the worst job markets would receive an additional 6 weeks. That additional time is desperately needed by Rhode Islanders, who, day after day, week after week, pore through the want ads looking for the job postings and hoping that the next interview will be the one that puts them back on their feet again.

I am confident the economy of Rhode Island and the economy across the country will recover. It always does. But right now it looks as though it will take time. Economists say the stock market tends to be a leading indicator of recovery, while employment numbers are lagging indicators of recovery. This means the recent uptick in the stock market should lead to more jobs being available in the future. But until then, unemployed Rhode Islanders such as Carole and Patricia, unemployed Americans across our country, need their government to help provide the bridge to those better days.

I implore my colleagues to join me in supporting swift passage of this urgently needed and--I hope once we cut through the fuss-- ultimately noncontroversial unemployment benefits extension.

I thank the Presiding Officer and yield the floor.

Madam President, I thank the Senator from New Mexico for organizing this time.

What do we mean by a public option? To begin with, I will explain a little

what our public option is and why it is so important. Then I have some stories from people in Rhode Island who have contacted me and who are exactly the reason we need to do this.

The first thing you will hear is our friends on the other side saying that the public option is a government takeover of the health care system, that it is going to squeeze out private providers and it will be subsidized by taxpayers and all these things. I know something about the public option that came out of the HELP Committee because, along with Sherrod Brown and Kay Hagan, I wrote it. So I know a little bit about what it does. Those things are just not true.

The design of the public option is that it exists State by State. In each State, it has to stay solvent. It can't lose money. The government puts up the money any insurance company needs to start with, the initial capital. After that, the public option in each State, from its revenues, the premiums it charges, has to make money and stay solvent. If not, it fails like any other company. Secretary Sebelius of HHS is mandated to make sure each State's operation runs on a solvent basis. So there is no taxpayer bailout. It is head-to-head competition on a level playing field, and the insurance companies, frankly, should not be frightened of it. They are, but the reason they are has a lot to do with their bad practices and very little to do with anything about the design of the public option.

One of the reasons we need it, to give a little background on this, you have to remember where our national health expenditures are going. Look at this chart. This is how much we spend on health care.

I was born in 1955, when we were spending $12.5 billion a year on health care in this country. We probably spend that much a day now. In 1979, just after I graduated from college, by then we had gone from roughly $12 billion a year to $220 billion a year. In 1987, which was about when my daughter was born, we were over $500 billion or $\1/2\ trillion a year. In 1992, we were at $849 billion a year. In 2009, we are at $2.5 trillion a year. You can see the shape of the curve on the chart. It is not going out and leveling off. It is getting steeper and steeper. Costs are going through the roof, and the private insurance industry is driving that.

There are big savings that can be achieved. The President of the United States, President Obama, and his Council of Economic Advisers issued a report in July of this year that said:

Efficiency improvements in the U.S. health care system

potentially could free up resources equal to 5 percent of the

Yes, I am happy to.

The opt-out plan, as I understand it, would allow States to decide they don't want a public option in their State, so they don't have to have one. Each of us comes here representing a State. My colleague is the very distinguished majority whip, but he is also the Senator from Illinois. Our distinguished friend, Mr. Udall, is the Senator from New Mexico.

The health care our constituents get is delivered to them almost entirely in our States. So one would think it would be satisfying to the people on the other side who object to a public option that they could go home and they could say: You know what. This public option is a terrible idea. You know what I have done. I have worked out an opt- out and have protected you from it. It is only these crazies in places such as Rhode Island who want to take advantage of the public option. But I have saved you, and it is their funeral.

The way we designed it, as I mentioned earlier, is State to State it has to be solvent. There is no cross-subsidization, that one State has to carry the water for another State. They would not have to pay for Rhode Island's costs if they got out of control, whether they have a public option or they do not. So they are protected.

One would think that would be an adequate argument for them. The fact that it is not an adequate argument suggests to me there is a little bit more at stake; that the real party in interest is not the constituents of their own States, it is the private insurance industry.

Absolutely, it is wide open, as the distinguished majority whip has pointed out. The choice would entirely be theirs.

I suspect what we would see is, many people who are railing against the public option right here would find that their States, when they actually had the choice, would take it. Ninety-four percent of U.S. insurance markets are deemed highly concentrated by the U.S. Department of Justice. That is like the alarm going off in those markets, saying that if you find anticompetitive behavior, because that market is highly concentrated, you focus on it. You have to act.

Ninety-four percent of our major urban areas are in that situation. So to add another choice for those consumers I think is something that when practical people look at it in real life and see what its effects will be in real people's homes and in their jobs and in their finances and in their world, it will be a lot harder to keep it going, but it will be their choice.

Yes, exactly correct. Unless they are involved in boycott or coercion, they can fix prices, carve up territories, do innumerable anticompetitive things that any other industry in America would have to answer for in a court of law. They get a pass on it because of the McCarran-Ferguson Act. But it shows, as the Senator from Illinois is pointing out, how vitally important competition is because that public option, I doubt it is going to sit down with private insurance industry and fix prices or carve up territories. It will have a public purpose and a public function, and it will be serving the people rather than the shareholders of the insurance company.

If the distinguished Senator will yield, the way this works out in individual people's lives--it is important for us as policymakers to understand what the Senator from New Mexico pointed out; that is, a 428-percent increase in insurance company profits in just 7 years, while they are turning people down and pushing them off coverage, even 47 million Americans uninsured, denying their claims, while the profits are going up like that. That is a very important story.

But then you get down to the actual people who get tangled up in this and what it does to their lives. Nicole from Providence, RI, wrote to me. In 2008, her doctor prescribed a number of tests she needed to take because she was experiencing stomach problems. Similar to many Americans who have gotten into these nightmares, they come in thinking they are all set, they have good health insurance.

Nicole thought she had good health insurance. She never imagined she would have any problem covering her medical costs. But the insurance company, once it started getting the bills, went scurrying around through its files and started to look for a way to get out of having to pay. Sure enough, they decided that her condition was ``preexisting.'' The magic word so they don't have to pay. Sure enough, they denied thousands of dollars of Nicole's claims.

So now there is Nicole. She thought she had insurance. She thought everything was fine. She had this stomach illness. She had to take these tests. She sends in the bills to the insurance company and they say: No, sorry, that is preexisting. So she is scrambling to pay off thousands and thousands in debt. That starts you off into the whole set of other problems, those administrative costs I was talking about. Those administrative costs are spent fighting patients, fighting their clients.

Here is Nicole constantly on the phone trying to get the correct documentation from her doctor to the insurance company, trying to get it to match up, and it never does and the bills keep coming. It is not only that she did not get the health care she needed and the company would not pay for it, it is when she tries to sort it out, she gets into this bureaucratic nightmare with that bureaucracy that grew 109 percent just in this decade arming up to fight people such as Nicole.

Here is what she concluded. This is a regular person from Providence, RI, snarled in the health insurance system. She says:

I have a full-time job with a good salary. I own a home. I

have health insurance. I am a middle-class American doing

everything I think I should. And yet I am now saddled with

thousands of dollars in medical bills that I cannot afford to

pay.

The stories go on and on of people in this system. Coreen from Cranston, RI, wrote me. She has health insurance through her employer, but the insurance company jacked up its premiums so high this year that her husband's employer was forced to switch to a high-deductible plan. She has a deductible of $2,000. So now Coreen and her husband take turns who is going to see the doctor, depending on which one of them they think is the most ill. The healthier one doesn't go and lets the one they think is sicker go. Do they know? Of course not, they are not experts, they are not doctors, but they have to make this decision because they have had this limitation put on their policy.

She wrote to me:

We have no other option but to be held hostage by our

insurer. In our current system, people come second and

profits come first.

For all the big picture stuff we are talking about, it is important to remember that all these big pictures come down to homes and families and people and workers all across this country, all of whom find that this health care system is a nightmare for them under the private health insurance regime.

May I inquire back if the insurance company, to the Senator's knowledge, actually checked to see if by taking the $3,000 colonoscopy they might find out something about his health so that in the long run everybody would save money because they did the test at the right time?

The public option, therefore, might be much more adept and likely at making that investment in the constituent's health because it is worth spending $3,000 for a colonoscopy if it will help prevent a catastrophic illness later on.

The story the Senator just told, reminds me of one. I do regular community dinners around Rhode Island. I go to a community, and we put out nothing fancy--pasta and meatballs, a salad and punch, and we invite people to come in and just have a general discussion about the issues that concern them.

At one of my recent community dinners, a lady spoke about some difficult run-ins with the health care system. The worst part of it was about her sister, who had the same situation as the Senator's constituent. She did not have health coverage and she missed an appointment with the doctor. She didn't want to put out the money, so she went without. By the time she actually did go to the doctor, the condition had worsened.

The doctor told the woman at my dinner: Your sister's condition, if she had come in earlier, we could have cured her. But as advanced as it is now, I don't think there is much we can do about it. They tried what they could, and it was very expensive, obviously, but ultimately they could not save her.

So when we don't get this right, and when people forgo health care because they can't afford it, and because our system is set up to not pay for things that are essential preventive care, people lose their lives. It is a matter of statistics and it is a matter of cost and it is a matter of tragedy, but ultimately it is also a matter, for many people, of life and death.

I would add another element in responding to Senator Durbin's question. They may very well be eligible for Medicaid or Medicare, in which case they would go on to those programs. But, if not, they would very likely be eligible under this health care reform for a significant subsidy to help them pay for health insurance.

What is interesting about the way that works is that they do not have to go into a government program to get the subsidy. We are trying to make health insurance more available to more middle-class families. So what they do is go to the health insurance exchange, which is like a market for health insurance or, if they work for a big company or the State or county or Federal Government, there is a period where they go and sign up for the health insurance they want.

Your H.R. person says: OK, now is the time to choose your policy for the coming year. They give you your choices and you select from your choices. You have a labor agreement or a contract agreement or a statutory provision that lets you know how much

your employer is going to contribute, but you get to choose, just like the Federal Employees Health Benefits Plan we are in--that all Federal employees are in.

That is the model, so that somebody who can't afford the insurance they want will get their stipend from the government and then they will go to the exchange and be able to choose. That is why it is called the public option. If there is a public option in that State, they will be able to choose the public option. If they do not like the public option, they can choose Aetna or Blue Cross or Wellpoint or Cigna or whoever is doing business in that State and buy through the exchange.

So for people in the circumstance the Senator talks about, who are in economic straits, this will be an easier way to buy health insurance. It will be a way they can afford health insurance, and it is a way that leaves the choice up to them. That is where the public option comes in because when they have that choice, I think for a lot of Americans looking at the way costs are going and looking at the way they get treated by the health insurance companies, they are going to say: The choice between all those for-profit health insurers, that is no choice at all. That is, which enemy do you have to sign up for? I use the word ``enemy'' because I have had people tell me the terrible thing about getting ill in this country is that they have to, on the one hand, fight the disease and, on the other hand, fight the insurance company. And they do see them, when they get involved in that, as the enemy.

When they have a choice between a whole bunch of insurance companies and they all share the purpose of trying to throw them off coverage if they are sick, trying to deny them coverage when they get sick, trying to deny the claims their doctor puts in, trying to interfere with what their doctor wants them to do to get better, if those are all their choices, that is not much of a choice.

That is where the public option can provide a real choice to people when they come in. They will have the dignity of being able to make that choice for themselves and their family through this program in our reform.

I see we are joined by the distinguished Senator from Colorado, Mr. Bennet.

(Mr. UDALL of New Mexico assumed the chair.)

Of course, anybody in the situation Senator Bennet described, if they don't like the idea of a public option under this legislation they are completely free to not sign up for it. Nobody in America will be forced into the public option. We don't even connect the subsidy, the stipend that makes health care affordable for American families, to the public option. We give it at the exchange in this legislation.

If you want to spend your government stipend to help make health care more affordable on Blue Cross, on Aetna, on Cigna, on whoever does business in your home State, you are welcome to do that. The public option is an absolute free choice. There is not a single person in this room, not a single person in the United States who, if the public option passes and they choose not to participate, has any adverse consequence at all.

The one thing they may have happen to them if the public option is successful is--if it is not sucking profits out of the system, if it is not building that huge administrative superstructure to fight with the doctors and hospitals so that they have to build a matching one to fight back from, if they are actually investing in, as you say, prevention and quality improvement and electronic health records and paying doctors in a sensible way so they don't have to run up procedures to get paid--if they do all that successfully, they will drive down the cost. Because it is competitive, those private insurance companies will have to follow. What you may get if you do not like the public option is you will get your stipend just like anybody else, if you are in the right income category. You will say I don't like the public option. I have no business with anything to do with the government health care, I don't want any part of it, I am going to the private sector--and you can buy that. You may in that circumstance actually see your private sector insurance rates come down because of nothing you did but because of the public option being out there and being competitive.

If the public option is uncompetitive and its rates go up, that is not going to hurt you. You are still in that private insurance company anyway. It is a ``heads I win, tails you lose'' situation for you; you are the winner on both sides.

I agree.

I think the Senator has made a very good point. I add to it by going back to the figures from the President's Council of Economic Advisers that suggest we could save $700 billion every year out of this health care system if we could wring the excess costs out of it--the unnecessary MRIs because you don't have an electronic health record and you have to go out and replicate it because you don't have the file with you; the totally unnecessary staff fighting with each other over who should get paid and who should not get paid; the $60,000 it requires, on average, when you get a hospital-acquired infection in the intensive care unit. If you could prevent it, you save. Those are the kinds of numbers that add up to these numbers. If you could save $700 billion a year--I am not saying you could do it, but it is a big target out there--investing $1 trillion over 10 years to get a piece of that back only makes sense. It is plain business sense.

If you were in the manufacturing sector and if you had an assembly line and that assembly line was creating costs like this, so the price of your product had to go up and up and you were having all those casualties, people were getting their hands caught in the machine and mangled and it was lighting up on fire because it was running out of oil, and you were having all these problems with the system, somebody would come in and say: You know what, you ought to spend a little money upfront to get a good system put in to fix up your assembly line because you will save costs in the long run. That is all we are expecting to do right now, is get those. There are so many disasters in the health care system right now, and to get that cleaned up and put a little money down for that, that is only good common business sense, particularly when there is a big target such as that $700 billion a year savings and, as you said, the cost of the next 10 years will be well north of $30 trillion if we do not do anything about this.

(Mr. BENNET assumed the Chair.)

If I may step in----

It was a team effort. I want to make sure that Senator Brown of Ohio, our friend Sherrod Brown gets recognized. He had a very important role in it. As the Senator knows, he is very committed on this issue and fights very hard to protect the interests of consumers. Senator Kay Hagan, our friend from North Carolina, also was extremely helpful. Because she has a more conservative perspective than we do, there was a wide range of views that were brought together. I think that is reflected in the fact that when the so-called Blue Dogs, the conservative Democrats over in the House, wanted to work out a public option, the public option they signed off on was the Senate HELP public option.

I think it has good appeal for conservative Democrats as well as progressive Democrats, that it reaches across the whole aisle. I hope by the time the dust settles, reasonable Senators of the other party will also join us in this because it only makes sense. If, as the President's Council of Economic Advisers says, it is ``possible to cut total health expenditures by about 30 percent without worsening outcomes,'' if there is 30 percent of waste and fighting you are talking about, and it adds up to $700 billion as the President's Council of Economic Advisers said, and if you add up the numbers from the Lewin Group, this here--they actually anticipate bigger savings, they anticipate $1 trillion a year in potential savings if--you could get all the excess costs out--it is $1 trillion a year--it is a phenomenal target to shoot for.

That is why making the public option competitive is such a good idea.

With this cost we cannot keep doing the same old thing and subsidizing. We have to change the direction of the health care system and the public option will do that.

Only to thank the Senator for organizing this time so we could engage in this colloquy on a matter that is so important to Americans on a matter where so much of what has been said has been so misleading and unhelpful.

The chance we have to talk about the actual public option as it is in real life, not some overheated imaginary public option that has been cooked up by the other side for the purpose of knocking it down, I think is very helpful to help the American people understand the direction we are trying to go. The Senator's role in getting this done is very much appreciated.

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

Mr. President, I have just returned from Afghanistan. I was there over the weekend. I wanted to take a moment and share a few impressions. I traveled with Senator Burr, who is a colleague of mine on the Intelligence Committee, and with Senator LeMieux of Florida. We visited Kabul, Jalalabad, and a military location further out in the field.

It was my third trip to Afghanistan. That makes me no expert. But I do hope my observations might be of some interest or use to my colleagues. Before I begin, our colleagues should know the perception in Kabul of how extremely valuable the efforts of our colleague Senator Kerry have been. It was clear the resolution that we saw to the election dilemma could not have happened without Senator Kerry.

The more our officials in Afghanistan knew about that situation, the stronger their views were about Senator Kerry's irreplaceable role. Even President Karzai commented on it in our meeting with him. So a well earned ``well done'' to our colleague and friend.

While the situation in Afghanistan is obviously complex and difficult, the best news for us is that the Taliban remains very unpopular. The Taliban's strength comes from the fact, not unreasonably, that many Afghans are terrified of them.

If the Taliban are willing to ride into town and cut off the ears of the village elder's son in front of the whole village, it requires considerable courage and confidence on their part in us and the Afghan Government for that village to stand up to those Taliban.

The Afghan people do not lack courage. Indeed, their courage and resistance in standing up to the Soviet invasion are among the reasons the Cold War is over, and why America is largely out of the shadow of that nuclear threat. When we think of our role in Afghanistan, it is worth considering our obligations in the light of what their struggle against the Soviet Union has meant for our country, our safety and our liberty. So courage is not something that Afghans lack.

But there is a compelling need for the Afghan people to feel confidence in their government and confidence in us. The best avenue to increasing Afghani confidence in their government will be reducing government corruption. It is a pernicious cancer throughout much of the Afghan Government.

Once this election is settled--and I will assume that President Karzai will emerge victorious--President Karzai can then turn his attention to his new administration. And then I think it is vital--and it is unanimously seen to be vital by the officials I spoke to--that vigorous efforts against corruption be a leading part of President Karzai's commitment to the Afghan people.

Confidence in us is equally important, but confidence in us must be measured against its counterweight, which is dependence on us. President Karzai, his ministers, and his challenger, Dr. Abdullah, are extremely grateful for the sacrifice that America has made for the benefit of their people, and they do not hesitate to say so. But at the same time, it is a realistic human impulse to be pleased if someone else will do something for you that you would otherwise have had to do yourself.

So, on the one hand, assuring the Afghan people of our reliable and enduring commitment to their struggle, while, on the other hand, ensuring that the Afghan Government meets its responsibilities, rather than just relying on us to fight their war, is the difficult balance we must achieve.

The more President Karzai--after this election is settled--can assume the mantle of a wartime President and accept responsibility that he is the military leader of this struggle, as well as the newly elected leader of Afghanistan, the better it will be. But it also seems to me that a strategic agreement with the Afghan Government, a strategic agreement that more clearly lays out the responsibilities and the commitments on either side, would be a good vehicle to set that balance.

The confidence of the Afghan people in our steadfastness is necessary to their willingness to fight this enemy, and the Afghan Government stepping up clearly to its responsibilities is necessary to our willingness to fight this enemy. Together, where those goals intersect, we can win. Divided, we cannot.

Sorting this out will not be easy. For too many years, we have been ``muddling through'' in Afghanistan. President Obama's appointee, General McChrystal, has now called for a new strategy. I think the President is wise and patient to think this through carefully as he leads us out of the muddle and develops a winning strategy.

No one I spoke to in Afghanistan thought the need for new troops was immediate. The 21,000 additional troops President Obama sent are still being absorbed. Winter is coming with its seasonal lull in the violence. Questions about Pakistan's role supporting the Taliban in Afghanistan are unresolved, questions whose answers will make our challenge in Afghanistan either far more easy or far more difficult. This is not simple and should not suddenly be rushed now, after years of muddling.

In evaluating the decision that President Obama faces, it is worth considering the actual report that General McChrystal provided. We have heard a lot about it, and most of it has had to do with the immediate deployment of troops.

The report, if you look at it, has a slightly different cast. In his report, General McChrystal identified ``two fundamental changes''--that is his quote--``two fundamental changes'' that are required.

One is this--and I quote--

ISAF must focus on getting the basics right.

ISAF is International Security Assistance Force. It is the international force that America leads in Afghanistan. Here is one: ``ISAF must focus on getting the basics right.''

Two:

ISAF must also adopt a new strategy.

Those are his one and two points--``getting the basics right'' and ``adopt a new strategy.''

To continue quoting General McChrystal's report:

The key take away from this assessment is the major need

for a systematic change to our strategy and the way we think

and operate.

Let me quote that again:

The key--

This is the McChrystal report quoted verbatim--

The key take away from this assessment is the major need

for a systematic change to our strategy and the way we think

and operate.

That is the task on which the President has embarked, and after years of muddling, I think he is entitled to a reasonable time to get it right.

I would like to highlight three of the areas that General McChrystal emphasized in his report.

I will quote again. One:

Tour lengths should be long enough to build continuity and

ownership of success.

Afghan society is deeply complex, personal, and it is governed by codes of conduct and honor. Our decisionmakers on the ground need to know the social terrain to be effective. That message has been loud and clear from my trips to that country. But the conclusion from the general is that ``Tour lengths should be long enough to build continuity and ownership of success.'' This will be hard on our troops and their families, and it will also be hard on the back-office bureaucracies that have to accommodate this. But that is what he said. There it is.

This is another quote. Two:

ISAF must operate differently. Preoccupied with force

protection, ISAF has operated in a manner that distances

itself, both physically and psychologically, from the people

they seek to protect.

An example of this is that the reconstruction of a bridge or a school is good and important and valuable, but if the convoy of MRAPs ran everybody off the road in all the villages that they went through on the way to that school or bridge, the signal that we are there to help is lost.

This is a hard point that General McChrystal has made: reducing the cocoon of force protection around our civilian and military personnel creates greater exposure to casualties. General McChrystal has faced this point squarely.

Third, and somewhat amazingly--I will quote again--

Major insurgent groups outperform GIROA and ISAF at

information operations.

Again, ISAF is the International Security Assistance Force. GIROA is the acronym for the Government of the Islamic Republic of Afghanistan. So I plug that into the quote and it says: Major insurgent groups outperform the Government of the Islamic Republic of Afghanistan and the International Security Assistance Force at information operations.

I will tell you, for a country that invented Madison Avenue advertising and public relations, this is a bitter pill. And this was confirmed during our trip. Although we saw a few areas that gave us hope, overall, officials acknowledged that information operations appear to be operating with far less sophistication and energy than tactical military operations.

I have the impression that for too long this function has been seen really as information supply rather than information combat. Everybody in this Chamber has gotten here--or at least almost everybody has gotten here--after having won an election in which they had to engage in prolonged information combat against the other side to get their message across. Our information operations do need to be improved in Afghanistan, and it is commendable that General McChrystal has recognized it.

Let me be clear. This is not propaganda. This is not making up a lot of spin. This is getting the facts out faster and better. As General McChrystal noted in his report--and I quote again--``this is `a deeds- based' information environment,'' but we do have the deeds. We have villages peaceful. We have markets opened. We have Taliban fighters turning in their guns to seek reconciliation.

We have, on the negative side, horrific Taliban atrocities that offend Afghan culture as well as our own--so that we can tell a winning and truthful story to the Afghan people, but, as General McChrystal has acknowledged, we have to get better at this.

I will conclude with an expression of gratitude and a final observation. We should be extraordinarily grateful to our Americans serving in Afghanistan, not just for their courage and sacrifice, which are remarkable in themselves, but also for their skill to fight an enemy of lunatics, criminals, and fanatics for whom no brutality is too offensive, while, at the same time, protecting the civilian population within which the enemy operates--all while protecting the values we Americans hold dear. That is no small trick.

The men and women who have developed this to an unprecedented level of competence--even mastery--deserve our commendation: the Rangers, on long and arduous patrols through harsh terrain; the special operations teams, working by night to disable enemy leaders; the interrogators, working far from home to develop intelligence about this enemy, well within the bounds of decency and the norms of military conduct, and very successfully; the analysts, at work 24/7, processing that intelligence to maintain nearly immediate situational awareness for our forces; the pilots, delivering goods and personnel wherever and whenever required; and the vast support structure that keeps those aircraft operational in one of the harshest environments on Earth; the marines, clearing and rebuilding villages in Helmand Province, not just rebuilding villages but rebuilding trust and security for those families; our silent services, whose only reward is their success and the respect of their peers; the reconstruction teams, working to bridge barriers of culture and language, and our own bureaucratic barriers, to rebuild the infrastructure of civilized life: schools for girls, roads to market--that is all just a slice of the courage, devotion, and skill that Americans are bringing to this challenge.

My final observation is this: Wherever I have been on three visits now, American soldiers of all ranks have a tangible respect and affection for their Afghan counterparts. The Afghan soldier could be centuries behind us technologically, but he comes from a martial tradition lasting thousands of years, producing men who are brave, resourceful, hardy, principled, and willing to fight.

I remember a bearded special forces officer telling me about the commandoes he was training, that when he went out on patrol with them, he had no hesitation. They called each other brothers. And he said there was not a man in his group who would not lay down his life to protect him. For all the difficulties we will face--and this is not easy--I think this aspect provides a platform for some optimism about growing an effective Afghan national military and police to assume its necessary role protecting Afghanistan's security and sovereignty and speeding our return home.

I thank the Presiding Officer. I yield the floor, and I note the absence of a quorum.

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

Mr. President, I ask unanimous consent to speak as in morning business.

Mr. President, 3 weeks ago we came to the floor of the Senate and asked our Republican colleagues to join us in a bipartisan effort to extend unemployment compensation benefits for those across America who have lost their jobs. This fairly routine and common political request was met with opposition from the Republican side. It came as a surprise because we know the unemployment we face in this country is not confined to States represented by Democratic Senators, it is nationwide. The recession has cost us so many jobs and, sadly, I am afraid that, although there are signs of recovery, it will be some time before many unemployed people actually do get back to work.

It is said there are six unemployed people for every available job. The frustration that creates for those who are unemployed is obvious. So the object of our request was to ask our Republican colleagues to join us in extending unemployment insurance benefits for those who are about to see them expire.

Unfortunately, the Republican side objected, and they objected because they said they wanted to offer some amendments. It is not unusual to offer an amendment to anything that comes to the Senate floor, but in the case of an emergency such as this, an economic emergency where people have, within the last few weeks or months, seen their livelihood extinguished because they have no job and no benefits coming in, it is a little hard to understand why some Members on the Republican side of the aisle insist on offering amendments that have virtually nothing to do with unemployment.

Let me give one example. The Senator from Louisiana wants to offer an amendment that would, once again, punish an organization known as ACORN. ACORN is not in Illinois--it has not been for many years--so I don't know on a personal basis, but from what I read, it is an organization involved in grassroots organizing. It helps organize States to pass increases in the minimum wage in each State. They have also organized to register voters in many States. They have been involved in counseling people who are about to lose their homes to avoid foreclosure.

Having said those good things, there were clearly acts of wrongdoing by employees of ACORN. In fact, a couple

were videotaped. What we saw on those videotapes, a few weeks ago, was nothing short of outrageous. The employees involved were fired by ACORN. I have suggested, if there is any criminal activity associated with it, it should be investigated and prosecuted, no ifs, ands or buts. But, unfortunately, this has become a big cause on rightwing radio and TV: go after ACORN. Some Senators are inspired by that to come to the floor on a frequent basis and offer ACORN amendments--one after another after another. We think some four or five different amendments have been offered, ways of punishing ACORN.

The House has already passed an amendment saying ACORN cannot do business with the Federal Government. There have been amendments offered--I have offered one of them--calling for a complete investigation of the organization. Other appropriations bills have limited any expenditures involving this organization. So it is not as if it has been ignored or glossed over or excuses are being made. There is a full investigation being ordered, action taken against it.

But for some Senators, particularly one from Louisiana, it is not enough. We have to go back and debate ACORN again. We have to debate it on a bill for unemployment benefits for hundreds of thousands of Americans.

Another Senator wants to extend a program called E-Verify. E-Verify, conceptually, is sound; that is, you could verify whether a person applying for employment is, in fact, a citizen; that you could have a number or computer contact verifying the name and Social Security number of the person. It is sound in principle, but it turns out in operation it has been a problem. Many times, the numbers have not matched when they should have, people have been disqualified from jobs when they should not have been, and the system clearly needs to be repaired and improved. It will last for 3 more years, this system, if we do nothing. A Senator from Alabama has come to the floor and said he wants to make this a permanent program, despite some of the obstacles and problems we currently have with it.

So a Senator from Louisiana wants to flog ACORN, this organization, again; a Senator from Alabama wants to extend a law beyond the 3 years it is going to be in existence to make it permanent; and they are holding up unemployment benefits for people all across America. We are now doing nothing in the Senate except making speeches because these Senators insist on their amendments and will not agree to unemployment benefits until they get them.

Twenty-one days after we requested an extension of unemployment benefits, the Republican Senators and leadership are continuing to hold us up. Two hundred thousand Americans will lose their unemployment insurance this month if the Republicans continue to obstruct a vote to extend the benefits. To put it in perspective, around 200,000 people live in Birmingham, AL, and in Montgomery and in Mobile. The Republicans are refusing to help roughly the number of people who live in the three biggest cities in that State, all because a Senator wants to vote to extend, permanently, the E-Verify Program.

Around 200,000 people live in Baton Rouge, LA, and in Shreveport as well. Republicans are refusing to help roughly the number of people who live in those two biggest cities in Louisiana outside New Orleans, all because the Senator from Louisiana wants one more chance to give one more speech for one more amendment about ACORN. Yes, one more.

Meanwhile, here is what I learned from one of my constituents in Chicago who wrote and said:

I have been out of work 9 of the last 12 months. I have

applied for over 200 jobs and I still am unemployed. I am

educated, worked since I was 15 years old and cannot find

work. I have applied for everything from hourly to above my

skill level including city and state jobs and have not heard

from most.

Further, Peoples Gas cut off my service this week--for

months I have let them know what I was able to pay and have

paid it, they still cut off my service. What are we citizens

to do. . . .

My son and I will be living on the street any day. Where is

the help?

That is from one of my writers from Chicago. Here is a letter from a woman in Genoa, IL.

. . . I am currently one of many who is unemployed and

almost out of benefits. I have 2 young children I am

responsible for and have made a full time effort to look for

work. I have applied at gas stations, McDonald's,

restaurants, everywhere. There are just no jobs. Can you

please tell me if the Senate will be voting on the extension

[of unemployment benefits] sometime soon? I am expecting my

last check next week and then I don't know what I am going to

do about keeping a roof over mine and my children's heads.

Please help us from becoming homeless. Any kind of response

on this issue would be greatly appreciated. Thank you.

How can my colleagues on the Republican side hear stories like that, if they are even listening to these unemployed people, and refuse to help so they can come to the floor and debate their amendments? For goodness' sake, tomorrow is another day. There will be another chance to give a speech and debate an amendment. Why wouldn't you let the unemployment compensation benefits go forward for people such as those who have written to me? The unemployment rate in my State is 10.5 percent, and I think it is my duty to help these people with a safety net that will help them get by while they are just one out of six applicants for every available job. While they struggle to keep food on the table and a roof over their heads, we ought to be doing our part in the Senate.

Apparently, yesterday when we voted to go to the unemployment benefits, 13 Republican Senators voted no, against moving to the extension of unemployment benefits. In case some of those Senators missed it, here are the unemployment rates in the States represented by the Republicans who voted against even debating an extension of unemployment insurance: Texas, 8.2 percent; Mississippi, 9.2 percent; Missouri, 9.5 percent; Alabama, 10.7 percent; Kentucky, 10.9 percent; South Carolina, 11.6 percent. I don't understand it. How could you represent a State with over 10 percent unemployment and vote against unemployment benefits for the people there who are searching for jobs? That, to me, does not represent family values. It doesn't represent what this Senate ought to be about. For goodness' sake, it doesn't represent the kind of bipartisanship that was always behind voting for unemployment benefits.

This Republican obstruction, when it comes to something this basic, is fundamentally unfair. It is way past time. We should not be playing games and posturing. We ought to stop the politics. We ought to be voting in the next 5 minutes so we can respond to the people who write to us in desperation and tell them, in fact, we are moving the bill forward so they will have the basics in life to take care of their families.

Health Care

I also wish to say a word or two about health care because that is the issue that, while we work on others, is coming to the floor soon for a historic debate. Senator Reid, the Democratic majority leader, has sent a bill to the Congressional Budget Office to score it, which basically means to find out will it cost us money. If so, will it add to the deficit? Will it reduce the costs of health care? The Congressional Budget Office is doing that analysis at this current time.

It is clear we desperately need this because we find fewer and fewer businesses offering health insurance across America, and the cost of health insurance is going up so fast people cannot afford it. The New York Times reported that insurance brokers and benefits consultants say small business clients are going to see premiums go up on health insurance an average of about 15 percent for the coming year. That is double the rate of last year's increase. When Republican Senators come to the floor--and they did this morning--and say: Let me tell you, if you pass health care reform, the cost of health insurance will go up, what they don't say is, if you don't pass health care reform, health insurance costs will go up anyway and possibly higher. What we are trying to do is slow the rate of growth in the cost of health care across America.

In one national survey, nearly three-quarters of small businesses that did not offer benefits cited high premiums as the reason. So as the premium costs go up and businesses offer less coverage, individuals have to go out on

their own and it is even more expensive. Small businesses pay up to 18 percent more than large firms. What we have tried to do in the health care reform we are working on is to give small businesses a chance. I joined with Senator Blanche Lambert Lincoln of Arkansas as well as Senators Snowe and Collins of Maine in introducing the SHOP bill, which has become part of the health care reform.

It is an effort which we put together with the help of the National Federation of Independent Businesses and the National Realtors Association and the SEIU labor union to try to find a way that small businesses could afford health insurance, allow them to pool into larger groups, allow them to shop from a market of health insurers so they would have some choice to lower the cost, the overhead costs they face, and to lower the premium costs, so small businesses could offer health insurance.

But it is not just small businesses that are stuck. Many Americans actually stay in jobs today because they are afraid that if they move from one job to another, they will lose their health insurance. Even business owners, the risk takers among us who have so often led us out of the recession, are less willing to take that risk when it comes to people who are sick and need employment.

Melissa Wilhelm in Chicago knows what I am talking about. Melissa spent years as a research associate, then decided it was time for a change in her professional life. She felt she had outgrown the position she was in. She said: I did not want to put the widget in the hole every day.

Melissa had good reason to want the most out of each day. Only a couple of years earlier, at the age of 35, Melissa had been diagnosed with stage IV lymphoma, an aggressive type of cancer that affects the lymph nodes. As frightening as her diagnosis was, one thing Melissa did not worry about was how she was going to pay for her cancer treatment. She had a good health insurance policy. In fact, she had two, one through her employer and another one through her graduate school.

In 2006, thank God, Melissa went into remission. It was after her recovery that Melissa decided it was the time for a career change. She wanted to start her own education consulting company.

Knowing her medical history, she knew her first step was to meet with a health insurance agent. Melissa said the agent actually laughed in her face. Getting affordable health insurance as a self-employed cancer survivor is apparently a laughable request in the world of insurance. Melissa was not alarmed at that point. She qualified for 18 months of COBRA coverage and assumed she would have enough time to shop around. But a couple of months later, she came home from vacation to bad news: her COBRA insurance had been terminated. She apparently missed paying one monthly payment. It had been sent to the wrong place. But for COBRA, since she missed the payment, it was the end of the story, the end of her coverage. She was not refunded the $2,000 she had already paid in premiums; they just cut her off. Suddenly, she became one of the uninsured, a cancer survivor without insurance.

She had one last option: the Illinois Comprehensive Health Insurance Plan, our State's high-risk pool, a pool for those individuals unable to buy health insurance otherwise. But the coverage would not come cheap; it would cost her $780 a month, plus a $2,000 deductible--a price she had no choice but to pay. As she waited for her coverage to be finalized, she put off checkups and CAT scans. It was risky, but, as she said: I did not want to drag myself and my family into bankruptcy. Those apparently were the choices: go to the doctor or face bankruptcy--not much of a choice in modern-day America.

We know health care costs are a major factor in two out of three bankruptcies in our country today. How many families can even entertain the idea of paying $25,000 a month for chemotherapy? Not many. And none of us should ever be in a position where professional growth is not an option because it means giving up health care coverage.

Melissa said: People do not have the ability to leave their jobs. They cannot afford to be more productive or more challenged. That is not the American spirit. And Melissa is right.

Melissa was living the American dream, pursuing new goals and opportunities with the entrepreneurial spirit we need in this country. But she was stopped--stopped cold because of her lack of health insurance.

Melissa eventually succeeded and started her business as an educational consultant. She is currently helping evaluate Chicago public schools at risk of failure and developing good practices so that students can do better. With a Ph.D. in child development policy, Melissa is certainly up to the task. I think we can use more people like her, determined to improve their lives even though they have to battle cancer and the health insurance companies at the same time. Health care reform will free more people to leave dead-end or unfulfilling jobs and to pursue new goals without fear of becoming uninsured.

Today, many of the unemployed spend countless hours trolling job sites, motivated at least in part by the desperate need for health care. What if these people had a safety net, a health care option outside of employer-provided health care? Maybe, like Melissa, they would strike out on their own, open the restaurant or the business they always wanted to open. Maybe those businesses would grow, employ more people.

It is clear that small businesses suffer in today's health insurance market more than most. It is extremely difficult for those businesses to compete against big firms that are able to spread the cost of unexpected illness across a large pool.

The bottom line is this: We have a health care reform bill that is now being carefully reviewed, as it should be. It is one we will debate at length. The critics will come to the floor, as they did this morning, and will tell us what is wrong with the bill. But the fact of life is, those who are criticizing the bill have no alternative. Their alternative is to stay with the current system.

The current system of health care in America is too expensive, the cost is going up too quickly, fewer and fewer people are insured each year, and more of us are bearing the costs of the insured as they are treated in hospitals and by doctors who pass along that cost to other people.

We are the victims of health insurance companies which on a whim can deny coverage, can claim there was a preexisting condition unreported or a cap on the amount of money they will pay, or the fact that you are sick, they just do not want to be there. That is the reality of what we face today.

Those on the other side of the aisle who will not participate have opted out of the health care debate and really have little room to criticize unless they want to step forward with their own proposal and their own plan. And the honest answer is, they don't have one. They don't have an answer.

I hear from many of my constituents who ask me what we are going to do to get this economy moving again. That is our highest priority. But in addition to that we have to liberate families and businesses and individuals from the fear they have of health insurance they can't afford, health insurance companies that just say no, or the fact that losing or changing a job can cost them the peace of mind they need to protect their families.

We can do a lot more for the American people. I hope we will have the cooperation of the Republican side in doing this. It would be great if we had a bipartisan bill. I hope my colleagues on the other side of the aisle will come around and be part of the solution.

I yield the floor.

Will the Senator yield for a question?

One of the aspects of the bill now being considered by the Congressional Budget Office is the opt-out provision. We have heard from the Republican side of the aisle for as long as this debate has gone on about their resistance and opposition to the idea of so-called government-run health care.

I have yet to hear the first Republican Senator come to the floor and suggest we eliminate Medicare, which is a government-run health care program which some 40 million Americans use every day to protect themselves when they need health insurance; nor have they suggested eliminating Medicaid, which involves health insurance for the poorest in America. Some 40 million to 50 million Americans are covered by Medicaid. They have not suggested eliminating veterans health care, another government health care program which helps millions of those who served our country; nor have they suggested eliminating the Children's Health Insurance Program, a creation of the Federal Government, so that literally millions of children across America have this kind of protection and the parents have peace of mind.

By my estimation, more than a third of the people in America have protection from government health insurance. Although our friends on the Republican side are critical of government health insurance, they do not want to eliminate any part of it, but they are arguing that basically Americans do not like it.

The polls say otherwise. When you ask the American people, throughout this debate, they say: We are generally confused, but we do know one thing; that is, if we have a chance to get Medicare for everybody, two out of three would like to see that. That is a government health program that two out of three Americans would like.

Senator Harry Reid, the Democratic majority leader, prepared a bill with a public option with an opt-out provision. I ask the Senator from Rhode Island what the opt-out provision will mean for those political leaders or people or legislatures or Governors in the States who might come to the same conclusion as our Republicans here, that they are opposed to any form of a public option that might involve the government.

If the Senator will yield, to put clarity and a final point on this, if this is enacted into law and a Governor or some leaders in any given State decide that the public option in their State, giving the people who live in that State an additional choice when it comes to the health insurance they want to buy, if they decide that is too extreme, too socialistic, too French--whatever they happen to decide--they could initiate an effort to eliminate the public option under this law so it would not apply to anyone living in their State. Whether these are the folks inspired by the tea party folks or others, they have their chance. They have the last word as to whether there will be a public option in their State.

If I can make one last point in a question. I know the Senator from Rhode Island is a former prosecutor, as is the Senator from New Mexico. When we come to the competitive nature of insurance companies--I know the Senator from Rhode Island was with me at a hearing recently in the Senate Judiciary Committee on the McCarran- Ferguson law, which in the 1940s exempted insurance companies--in this case, health insurance companies and medical malpractice insurance companies--from antitrust regulations, so that literally the executives of insurance companies--in this case health insurance companies--could all meet in a room and decide what the premiums would be in any given place in America, across the Nation. They could meet together and come to a common agreement as to which States would be dominated by which companies and, as I understand the McCarran-Ferguson law, the Federal Government would have no power to stop them.

We can stop virtually any other group of companies trying to do the same anticompetitive things, but there is no power to stop the health insurance companies because of McCarran-Ferguson under our Federal antitrust laws.

I say to the Senator from Rhode Island, does this not also suggest that when the health insurance companies threaten they are going to raise premiums, we ought to take them seriously? They have the power to do it,

and they certainly have a long, rich history of doing that. So when they say: If you pass health care reform, we are going to raise premiums, count on it; they are going to do it.

If we do not create the competition of a not-for-profit public option health insurance company, they literally will not face competition.

If the Senator will yield, I would like to note that I received a similar letter from a man in Illinois who had a $5,000 deductible because he had a history of illness. So in order to buy health insurance he could afford, he had to be willing to first put out $5,000 in cash out before they would cover the first dollar. He was told by his doctor, because of an examination, that he would need a colonoscopy, which is rather common and certainly a thoughtful thing to do when there is an indication. But he found it would cost him $3,000 out-of-pocket for a colonoscopy, and he would have to pay that because the insurance plan didn't cover it. He didn't have the $3,000.

Well, I don't know the answer to that, but I would suspect that they did not because the concern for that insurance company is the bottom line for that quarter. They are not concerned, as they should be, about the long-term health of this man. If there is an indication that leads to a colonoscopy, it makes common sense that you would do it because things

discovered early can often be treated successfully, and things that you don't treat can turn into very expensive and deadly diseases.

That is the key word, ``prevent.'' We have to move toward a new mindset that health insurance companies don't think about-- wellness and prevention. If we put a little money into those, we can keep people healthier and keep costs down.

I am sure the Senator from Rhode Island and the Senator from New Mexico will recall the visit we had from the CEO of a major grocery store chain--Safeway/Dominix--and how they decided for their management to try to do preventive care. I recall the CEO telling us that because of preventive care, they have been able to keep their health insurance, which is a self-insured plan, even for 3 straight years without increases.

So prevention and wellness not only keep people healthier but reduce cost. But if you were trying to drive the bottom line and just said no to people who need a colonoscopy or need a mammogram or prostate cancer treatment, diabetes maintenance--if you are saying no to all of those things and those people--the ultimate cost in human life and in dollars goes through the roof.

If the Senator would yield once again, I would like to make note for the record that we are on the Senate floor this evening, and we have time to speak on this important issue because the Republicans are blocking our efforts to pass a bill that sends unemployment compensation to literally hundreds of thousands of Americans who have been out of work for a long time and need these checks to keep their families together. They have now resisted us for 21 days to extend unemployment benefits to these people across America. I am sure in each of our States, as I found in Illinois, many of these unemployed people have also lost their health insurance as a result of losing their jobs.

I would like to ask either or both of the Senators to comment on what this health care reform proposal that we are talking about would do for a person who has either lost a job or is in a low-income category; someone who is scraping by with a low-wage job, hoping for something better, or maybe that is the best they can come up with.

Would either of the Senators like to respond as to what this legislation, our health care reform bill, is proposing?

If the Senator from Rhode Island will yield, on his chart on national health expenditures, I have heard my colleagues on the other side of the aisle, the Republican side, come to the floor many times and decry this whole effort because it was going to cost $1 trillion. We are not sure if that will be the exact number, but take it as an example. We are talking about $1 trillion over the next 10 years. If you accumulate the cost of health care in America over the next 10 years, starting this year at $2.5 trillion, and assuming it goes up to at least $3 trillion, maybe $3.5 trillion, it seems to me we are dealing, over that period of time, with an accumulated cost of health care in America over 10 years of $30 to $35 trillion, I think, is probably a fair estimate.

One trillion dollars as a percent of that comes out to less than 3 percent of the overall cost of the system and the savings we are trying to build into this approach, by trying to find ways to reduce costs, to reduce the fraud and waste that is part of health care today, to give people options so that they have more competition, bringing down the cost of premiums--I would say to my friends on the other side of the aisle arguing that $1 trillion is a huge sum, certainly when you deal with $1 trillion it is, but in comparison to the overall cost of health care over the next 10 years it is less than 3 percent of what we anticipate. And it is largely made up of savings within the current system. I think that is the point they miss when they use that figure on the floor so frequently.

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

Madam President, I ask unanimous consent that I be allowed to proceed as in morning business.

Thank you, Madam President.

We are in a time when we are talking about money; we are talking about debt; we are talking about taxes; we are talking about stimulus; and we are talking about health care. I wish to put the whole situation with respect to money into some perspective.

Having been a businessman, I did my best to try to draw up a balance sheet for the United States. This is a very simplified balance sheet. It is in summary numbers only. But by going to the Federal Reserve Board and the Social Security and Medicare trustees and the Census Bureau, I have come up with the following balance sheet for citizens of the United States.

We start out with assets and liabilities. These are personal assets and personal liabilities. It is amazing to me that the number of household assets on a per-person basis is this high, but it is. If you take all of the personal assets in the United States, lump them together, and then divide them by the number of people in the United States, you get personal assets of $218,000 per person, and personal liabilities or household debt of only $45,000 per person. So the balance sheet looks pretty good.

However, as citizens of this country, we have debt beyond our personal debt. So when we add the national debt and each individual's share of it to the balance sheet, that adds an extra $37,982, so that the amount of debt goes up when you add each individual's share of the national debt.

The national debt is not the only debt we have. Let's add State and local government debt on a per-person basis, and it goes up another $7,500. But that is not the only debt we have. We have obligations, each one of us, with respect to Social Security. There is a Social Security liability and the present value of that Social Security liability is another $17,251 per person.

All right. It still looks like a pretty good balance sheet. With the assets at $218,000, this is about half. But there are two other liabilities we have to put on the balance sheet. The first one is the present value of Medicare hospital insurance. Over the next 75 years, the present value of that unfunded liability is $43,616 per person, almost as much as the total amount of debt that each one of us has as an individual. Now the balance sheet is looking a little scarier.

But we have one more item we have to put on the balance sheet, and that is the present value of Medicare supplemental medical insurance, and that is another $79,095 per person. So when you add it all up, this is the balance sheet we are facing today: $218,000 in assets, and $231,000 in liabilities. If this were a corporation with this balance sheet, we would say the corporation is underwater.

As we begin to break this down, we realize that the Medicare liability is more than everything else put together. The Medicare liability is more than our personal debts, our share of the national debt, our share of State and local debts, and our share of Social Security. The Medicare liability is more than all of that put together. Is it any wonder, then, that the No. 1 issue we should be talking about when we are talking about health care is how to get the health care costs under control; to use the terms that the budgeteers use, how to turn the cost curve downward on health care. We can talk about earmarks. We can talk about spending on appropriations bills. We can talk about holding down discretionary spending on other issues. All of those things are worth talking about, but they are dwarfed by the challenge of turning down the cost curve on health care.

I have said this before, but it still works: One of the statements that has gotten into American folklore is a statement attributed to Willie Sutton. Willie Sutton was a bank robber. Not very many people knew much about his robbing banks, but he kept doing it. He would get arrested, he would get out on parole or he would leave prison and he would rob another bank. Finally someone said to him: Willie, why do you keep robbing banks? He said: Because that is where the money is.

If we are going to talk about the balance sheet that every American faces in debt and debt obligations, we have to talk about health care because that is where the money is: more for health care liabilities than everything else put together.

Let's discuss this question of turning the cost curve down. How good a job have we done as a government in making projections as to the cost of health care? On the second chart, let's look at the years and at the projections. In 1965 when Medicare was first proposed, we made a cost projection. We, the government, made a cost projection as to how much it would cost us, and that is represented by that red bar there on that chart. Then the actual numbers came in, and they are represented by the green bar on the chart. Let's look at 1965 Medicare hospital insurance. That is a separate program. The cost projection is there in the red bar; the actual figures that came in are in the green bar. In 1987, we added Medicaid, and the Congress told the people: Medicaid won't cost much at all. You see, it is hard to find even on the chart. The actual cost was 17 times the projection that was made. In 1988 we added Medicare for home care. It was going to cost a little more. Once again, the gap between the red bar and the green bar--it has always cost more. We did a little better with SCHIP, but SCHIP is still a relatively new program, created in 1997, so the disparity between the projection and the reality is relatively small, but, once again, the reality has been greater than the projection.

There is one exception, and that is Medicare Part D, and that is the final pair there. The red bar shows what was projected that Medicare Part D would cost and the green bar shows, almost magically, this one costs less than the projection. Why?

I wish to quote from an editorial in the Wall Street Journal where they quote from White House Budget Director Peter Orszag. Peter Orszag was the head of the Congressional Budget Office at the time that cost projection was made. This is what the Journal has to say:

But as White House budget director Peter Orszag told

Congress when he ran the Congressional Budget Office, the

``primary cause'' of these cost savings is that--

quoting from Orszag

the pricing is coming in better than anticipated, and that is

likely a reflection of the competition that is occurring in

the private market.

I will repeat that: That is a reflection of the competition that is occurring in the private market.

The Journal goes on to point out something I recall, because I was here during that debate. I was part of that debate. The Journal says:

Liberal Democrats fought that private-competition model

(preferring government drug price controls), just as they are

trying to prevent private health plans from competing across

state borders now.

The lesson here is that spending on nearly all federal

benefit programs grows relentlessly once they are

established. This history won't stop Democrats bent on

ramming their entitlement into law. But every Member who

votes for it is guaranteeing larger deficits and higher taxes

far into the future. Count on it.

The history of cost containment with respect to health care is not a pleasant one. The history of predicting what health care will cost is not a pleasant one. The only example we have where costs have come in lower than projected has been in that circumstance where competition in the private sector has been protected. That has been the core of the bill Senator Ron Wyden and I have introduced as the Healthy Americans Act: private competition absent a government plan. We look at the history and see that will turn the cost curve down. That will begin to save money.

CBO examined our bill. Peter Orszag was the head of CBO when they looked at our bill and said it is revenue neutral--that is a good start--and then likely to save money in the future. They didn't put a number on it, but the Lewin Group has put a number on it and said that the Healthy Americans Act, cosponsored by Senator Wyden and myself, would save $1.3 trillion over the next 10 years. I don't know whether that number is right or wrong. I do know. It is wrong. I don't know how far wrong it is. But the point is it demonstrates turning the cost curve down rather than turning the cost curve up. And that is what we have to

do, as our balance sheet reminds us so dramatically.

Let me talk briefly about the idea of a government-run plan, a public option, or whatever it is we want to call it, as the way to turn the cost curve down. Once again, the history of government plans is not encouraging as far as turning the cost curve down as we look at Medicare and how little it was supposed to cost and how dramatically much it has cost.

Let me quote Robert Samuelson from his column that appeared in the Washington Post recently:

Medicare has low marketing costs because it's a monopoly.

But a non-monopoly public plan would have to sell itself and

would incur higher marketing costs. Private insurers' profits

(included in administrative costs) also explain some of

Medicare's cost advance. But profits represent only 3 percent

of the insurance industry's revenue. Moreover, accounting

comparisons are misleading when they don't include the cost

of Medicare's government-supplied investment capital.

So we are trying to mix apples with oranges when we say, look at the low administrative costs with Medicare and the high administrative costs with private insurance. Medicare can do it cheaper. Every projection about Medicare doing it cheaper has demonstrated not to work out.

Samuelson says this:

The promise of the public plan is a mirage. Its political

brilliance is to use free-market rhetoric (more ``choice''

and ``competition'') to expand government power. But why

would a plan tied to Medicare control health spending, when

Medicare hasn't?

. . . A favored public plan would probably doom today's

private insurance.

I think that is true. That is one of the reasons I am opposed to that kind of thing.

Samuelson goes on to make this final comment:

Many would say: Whoopee! Get rid of the sinister insurers.

Bring on a single-payer system. But if that's the agenda, why

not debate it directly? It's not insurers that cause high

health cost; they're simply the middlemen. It's the

fragmented delivery system and open-ended reimbursement.

Would strict regulation of doctors, hospitals and patients

under a single-payer system provide control? Or would genuine

competition among health plans over price and quality work

better?

That's the debate we need.

I agree. That is the debate we need. That is the debate that focuses on, how do you get this cost curve under control? How do you start to turn it down? How do you get the kind of score that Senator Wyden and I have gotten from CBO that says our plan is revenue neutral and that others say will save $1.3 trillion over the next 10 years, compared to the cost history of government-run plans that say they are only going to cost this much and end up costing that much and driving us to this kind of present value liability--twice as much as everything else put together. That is a staggering thing to contemplate, but that brings us back to what I said in the beginning. The core of this debate should be focused on how we turn the cost curve down.

I have one more comment to make with respect to that. As I have worked with Senator Wyden over the last 3\1/2\ years to try to understand this issue and come up with solutions to it that make marketplace sense rather than political sense, I have come to a great truth that we don't seem to be discussing in this debate at all, and that is this: The greatest cost control factor in health care is quality. The best health care is the cheapest. And we have built into the system now incentives that drive us away from the best care. Most of the perverse incentives that drive us away from the best care and to the highest costs are in Medicare. They are in the Medicare system that has gone 10 times, 20 times above its original cost, and they are still there, and the care they produce is less than the maximum care people can get when they go to the places that give us the best health care.

It is parochial for me to repeat this, but I am happy to do it on every occasion. Dartmouth has done a study as to where the best care is available throughout the United States, and they said it is in three cities: Seattle, WA; Rochester, MN; and Salt Lake City, UT. And then they say that if every American got his or her health care in Salt Lake City, UT, it would be the best in the United States and one-third cheaper than the national average, and that is because of a variety of reasons. They practice the best health care, and they have focused on outcomes rather than the kinds of perverse incentives that are built into government-run programs.

We have a lot to do and a long time to go before this health care debate is finished, but I hope we recognize that hanging over us, regardless of everything else we say with respect to health care, is the fiscal reality that our current value obligations for health care dwarf every other debt we have in the United States. Personal household debt, the national debt, State and local debt, and Social Security debt all put together do not add up to the amount of health care debt we are facing.

The challenge of turning the cost curve on health care down is the No. 1 issue we should be addressing as we are talking about this. The irony of it is, if we are successful based on what we know, we can get the cost curve down and produce a better health care outcome and result.

I yield the floor.

Mr. President, I ask unanimous consent that I be allowed to proceed as in morning business.

Mr. President, it has been a little over a year since a group of us met in the Foreign Relations Committee room headed by the distinguished Senator from Connecticut, Mr. Dodd, to talk about the financial crisis we were facing and how we would deal with that. We came out of that meeting, held a press conference where we sounded perhaps more optimistic than we should have at the time about having a solution to that problem. And out of that has come now a name that is well known throughout the country called TARP. We did not call it that at the time.

But we talked it through in a completely bipartisan and substantive way and voted for the rescue package that came out of that discussion. I voted for that package. I voted for the original disbursement of TARP. I stand by that vote a year later. It was the right vote, the right situation, the right time, and the right thing to do.

But I will share now some of the thoughts that went into my participation in that particular meeting and some of the things that came out of it. In anticipation of the meeting, I called some people whose judgment I trust and discussed this. I was told Treasury cannot physically push $700 billion out the door. You cannot sign that many contracts. That is far too much money.

The suggestion I made was: Why don't we give them $50 billion, because I was told that is the most they could spend in any one month. Why don't we give them $50 billion for 5 months or $250 billion and see how it works before we buy into the $700 billion number that Secretary Paulson was talking about.

No, Secretary Paulson let us know he had to have $700 billion as the headline. He could not calm down the markets, the international markets, unless he had a number that big. We talked it over in that room and came up with this solution, which I think was a good one. We would give them a $700 billion headline, because we authorized $700 billion, but we actually only gave him $350 billion and said he would have to come back to the Congress for the second 350.

Also in that group--and it was not by any means my suggestion or anyone else's suggestion--it was overwhelmingly the consensus: We have to put some controls in here. We have a congressional oversight committee that we created. We have to create an inspector general. I remember one of the members of the group saying: I do not trust any Treasury Secretary, no matter how bright he is, with $700 billion and absolutely no reporting or transparency or control situation.

One of the things that was discussed and that I thought was put in the bill was that when the money starts to come back--because, understand, TARP was not a bailout program in the sense that we gave money to people never to recover anything. It was a program where we were acquiring things, either acquiring collateral or acquiring stock. When the money starts to come back, it will be used to pay down the national debt. If we are going to expend $700 billion to stabilize the system, when the $700 billion comes back, it goes to reduce the debt that was created when it went out. That was my understanding of the agreement we made.

Well, I voted for the TARP and I voted for the first $350 billion. After we came to the second tranche, the second $350 billion, listening to the inspector general and listening to what the congressional oversight committee had to say, and looking at how well the first $350 billion had worked in stabilizing the situation and getting us past the panic we were facing, I voted against the second $350 billion because I was afraid it would turn into somewhat of a bailout fund that could be used for things other than acquiring assets that could be liquidated and bring money back to the Treasury. That is indeed what has happened, because much of the money went for things very different than that which we were talking about in that room that morning.

The amendment I will offer to the bill, when we get on the bill, will be to sunset TARP at the end of this year. This is where we are. Treasury is sitting on about $370 billion in the TARP fund right now. The recession certainly is not over and the challenge in our economy is still there with tremendous force. But the crisis we were facing when we had that meeting is over, and Treasury, to deal with that kind of a crisis, no longer needs that money.

The fear I have is that Treasury is starting to recycle the money and it is not going to pay down the national debt. It has become something of a slush fund to say: All right, if we have a circumstance here where we wish to spend some money, we cannot get it from the Congress, let's take it out of the TARP. If there is a situation over here where we think it might be helpful, and we cannot get the Congress to support us, let's take it out of the TARP. The temptation, sitting on $370 billion, to spend that money, is overwhelming.

When Secretary Geithner came before the Banking Committee or the Joint Economic Committee--I am sorry, I cannot, with my memory right now, put the exact committee to it--the question arose about repaying the national debt rather than recycling the money. He said the lawyers from the Treasury Department had looked at the act of Congress, and they made it clear we in the Congress had made it clear the money could be recycled, it could be relent, it could go out again. That came as a great surprise to me because I thought the conversation we had in that room, as the bill was being written, made it clear the money had to go to pay down the national debt. But I am not in a position to sue the Treasury and argue with their lawyers, and even if we did over the actual meaning of what was in the bill, it would take so many years to adjudicate there is no point in it.

But it comes as a great surprise, as I say, to me that as the money comes back in--and money is coming back in from TARP--it does not go to pay down the national debt, and that it is being treated as a revolving fund, almost a revolving credit card, if you will, that the Treasury can use for the purposes it deems well.

So I will offer an amendment that will sunset TARP at the end of this year. I will point out, the inspector general and the congressional oversight committee we set up on that occasion still have a number of questions about TARP and the way it is being used, and there is great concern that the transparency we had hoped for is not there.

I had come to the decision to offer this amendment for myself and Senator Thune--and we will do so, if we are allowed to, when we get on the bill--long before the Wall Street Journal offered an editorial. But on October 27, the Wall Street Journal had an editorial entitled ``Rolling up the TARP,'' which I ask unanimous consent be printed in the Record following my remarks.

The lead paragraph I wish to quote. It says:

The Troubled Asset Relief Program will expire on December

31, unless Treasury Secretary Timothy Geithner exercises his

authority to extend it to next October.

They obviously did not know about my amendment or I am sure they would have endorsed it.

We hope he doesn't. Historians will debate TARP's role in

ending the financial panic of 2008, but today there is little

evidence that the government needs or can prudently manage

what has evolved into a $700 billion all-purpose political

bailout fund.

We supported TARP to deal with toxic bank assets and

resolve failing banks as a resolution agency of the kind that

worked with savings and loans in the 1980s. Some taxpayer

money was needed beyond what the FDIC's shrinking insurance

fund had available. But TARP quickly became a Treasury tool

to save failing institutions without imposing discipline

(Citigroup) and even to force public capital onto banks that

didn't need it. This stigmatized all banks as taxpayer

supplicants and is now evolving into an excuse for the

Federal Reserve to micromanage compensation.

I think we take the decision for Secretary Geithner and we sunset TARP on December 31, and that will be the amendment I will offer when we get on the bill.

Exhibit 1

[From the Wall Street Journal, Oct. 27, 2009]

Rolling Up the TARP

The $700 billion for banks has become an all-purpose

bailout fund.

The Troubled Asset Relief Program will expire on December

31, unless Treasury Secretary Timothy Geithner exercises his

authority to extend it to next October. We hope he doesn't.

Historians will debate TARP's role in ending the financial

panic of 2008, but today there is little evidence that the

government needs or can prudently manage what has evolved

into a $700 billion all-purpose political bailout fund.

We supported TARP to deal with toxic bank assets and

resolve failing banks as a resolution agency of the kind that

worked with savings and loans in the 1980s. Some taxpayer

money was needed beyond what the FDIC's shrinking insurance

fund had available. But TARP quickly became a Treasury tool

to save failing institutions without imposing discipline

(Citigroup) and even to force public capital onto banks that

didn't need it. This stigmatized all banks as taxpayer

supplicants and is now evolving into an excuse for the

Federal Reserve to micromanage compensation.

TARP was then redirected well beyond the financial system

into $80 billion in ``investments'' for auto companies. These

may never be repaid but served as a lever to abuse creditors

and favor auto unions. TARP also bought preferred stock in

struggling insurers Lincoln and Hartford, though insurance

companies are not subject to bank runs and pose no ``systemic

risk.'' They erode slowly as customers stop renewing

policies.

TARP also became another fund for Congress to pay off the

already heavily subsidized housing industry by financing home

mortgage modifications. Not one cent of the $50 billion in

TARP funds earmarked to modify home mortgages will be

returned to the Treasury, says the Congressional Budget

Office.

As of the end of September, Mr. Geithner was sitting on

$317 billion of uncommitted TARP funds, thanks in part to

bank repayments. But this sum isn't the limit of his check-

writing ability. Treasury considers TARP a ``revolving

fund.'' If taxpayers are ever paid back by AIG, GM, Chrysler,

Citigroup and the rest, Treasury believes it has the

authority to spend that returned money on new adventures in

housing or other parts of the economy.

A TARP renewal by Mr. Geithner could thus put at risk the

entire $700 billion. Rep. Jeb Hensarling (R., Texas) and

former SEC Commissioner Paul Atkins sit on TARP's

Congressional Oversight Panel. They warn that the entire

taxpayer pot could be converted into subsidies. They are

especially concerned about expanding the foreclosure

prevention programs that have been failing by every measure.

TARP inspector general Neil Barofsky agrees that the

mortgage modifications ``will yield no direct return'' and

notes charitably that ``full recovery is far from certain''

on the money sent to AIG and Detroit. Mr. Barofsky also notes

that since Washington runs huge deficits, and interest rates

are almost sure to rise in coming years, TARP will be

increasingly expensive as the government pays more to borrow.

Even with the banks, TARP has been a double-edged sword.

While its capital injections saved some banks, its lack of

transparency created uncertainty that arguably prolonged the

panic. Federal Reserve Chairman Ben Bernanke and former

Treasury Secretary Hank Paulson recently admitted to Mr.

Barofsky what everyone figured at the time of the first

capital injections. Although

they claimed in October 2008 they were providing capital only

to healthy banks, Mr. Bernanke now says some of the firms

were under stress. Mr. Paulson now admits that he thought one

in particular was in danger of failing. By forcing all nine

to take the money, they prevented the weaklings from being

stigmatized.

Says Mr. Barofsky, ``In addition to the basic transparency

concern that this inconsistency raises, by stating expressly

that the `healthy' institutions would be able to increase

overall lending, Treasury created unrealistic expectations

about the institutions' conditions and their ability to

increase lending.''

The government also endangered one of the banks that they

considered healthy at the time. In December, Mr. Paulson

pressured Bank of America to complete its purchase of Merrill

Lynch. His position is that a failed deal would have hurt

both firms, but this is highly speculative. Mr. Barofsky

reports that, according to Fed documents, the government

viewed BofA as well-capitalized, but officials believed that

its tangible common equity would fall to dangerously low

levels if it had to absorb the sinking Merrill.

In other words, by insisting that BofA buy Merrill, Messrs.

Paulson and Bernanke were spreading systemic risk by stuffing

a failing institution into a relatively sound one. And they

were stuffing an investment bank into one of the nation's

largest institutions whose deposits were guaranteed by

taxpayers. BofA would later need billions of dollars more in

TARP cash to survive that forced merger, and when that news

became public it helped to extend the overall financial

panic.

Treasury and the Fed would prefer to keep TARP as insurance

in case the recovery falters and the banking system hits the

skids again. But the more transparent way to address this

risk is by buttressing the FDIC fund that insures bank

deposits and resolves failing banks. The political class has

twisted TARP into a fund to finance its pet programs and

constituents, and the faster it fades away, the better for

taxpayers and the financial system.

Mr. President, I enjoyed the comments of the distinguished Senator from Rhode Island. He is one of the most thoughtful and intelligent Members of the Senate. I always enjoy listening to him. But I have a different characterization of what we are doing in the Senate.

He pointed out that the majority leader believed it was necessary to cut off debate 82 times; that was a record. I do not believe I would be bragging about that. This is the Senate. What that means is the majority leader has said to the minority: Be quiet. Don't debate. We don't want your amendments--82 times.

The House of Representatives is the place where we have the train that runs through according to the majority. That is not the Senate. Senator Byrd, the senior Democrat, the senior Senator, has written four big volumes about the history of this body and what is unique about the Senate. Our Founders said: We will have one popular body where there is one man one vote, one woman one vote, and whoever has the majority the train runs through. So whatever Speaker Pelosi wants, Speaker Pelosi gets. That was the view of the Founders more than two centuries ago. But we are going to have a little bit different Senate.

Do you know what the idea of the Founders was, the Founders, whom we revere and admire? Unlimited debate. Unlimited amendment. That is the Senate. That is the only reason we have it. There is no need for the Senate if we do not have that.

When Alexis de Tocqueville, the young Frenchman, came to this country in the 1830s and wandered around our Nation and wrote that perceptive book, ``Democracy in America,'' which every serious student of the American Constitution in our country discovers, he saw one thing he worried most about in the new American democracy, and it was, in his words, the tyranny of the majority. He said the Senate was the one institution which helped work against the tyranny of the majority.

So this is the body that protects the minority view. It does slow things down. In the case we are talking about, unemployment compensation, we have already voted to limit debate on unemployment compensation. That is what we are talking about today.

I see the Republican whip on the Senate floor. As I recall, the vote to limit debate on unemployment compensation was overwhelmingly bipartisan, was it not?

Of course.

Mr. President, I ask unanimous consent that the Senator from Arizona and I be allowed to engage in a colloquy on this subject.

I believe the answer is no. If I am not mistaken--if I am not mistaken--I say to my friend from Arizona, the Democratic side has a nongermane amendment they would like the Senate to bring up, and I believe the Republican side has a nongermane amendment we would like to bring up. They are saying: Because we are in the majority, we are going to run over you. That is the tyranny of the majority. That is what Alexis de Tocqueville warned against, and we are saying: No, you are not. We are elected from Arizona and Tennessee to represent our constituents. If you are going to run over us, we might as well go home.

Mr. President, I think the Senator is exactly right, and we on the Republican side--and I believe some Democrats do as well--have some proposals about how to restart housing. We would like to deal with that on this issue as well. But the Senator is exactly correct. The No. 1 issue for most Americans is what to do about jobs. Unemployment is about at the rate of 10 percent.

The Senator from Arizona is correct. And as a member of the Finance Committee, he has once again come up with a very good suggestion. He understands better than some appear to that if we add taxes to payrolls, it makes it more likely that payrolls will be smaller or there will be fewer jobs. So if we can find a way to pay for unemployment compensation that does not add to the debt and does not add to payroll taxes, that is worth taking a little time to do.

Mr. President, if the Senator from Arizona has another minute, I thank him for coming to the floor because he has pointed out the value of taking a little time on these important pieces of legislation. He has suggested a way we can not only extend unemployment compensation benefits, which almost all of us want to do, but a way to pay for it in a way that creates more jobs rather than fewer.

There is another example. The Senator from Rhode Island was complaining about the 82 times that the majority leader has invoked cloture, and I was saying that was nothing to brag about. We should be complaining about that, because that is 82 times he has cut us off. In general, he has allowed during this year a fair amount of amendments, a fair amount of debate. But take the health care bill for a moment. It takes a little time. Over in the House I hear they may run that through in 3 days. That is not going to happen here. When we have time to stop and think about it--the same thing happens on this floor that happened last week. We had our first vote on health care and the question was, Shall we raise the debt \1/4\ trillion dollars?, and 13 Democrats joined all Republicans and said no.

We have another important vote coming up soon that might be called a procedural vote but, in fact, is a vote for or against a bill.

We are here every day. We want to do what the Senator from Arizona said. We want to read the bill and we want to know what it costs because when we hear about it--and the Senator from Arizona was a part of the Finance Committee that developed one bill; I was a part of the HELP Committee that developed another bill. What we hear is that instead of lowering premiums, which is the idea for 250 million Americans, it will probably raise premiums; that it will raise taxes; that it will cut Medicare by $450 billion.

Now we learn from the majority leader this week that there will be a new government-run insurance program. We are going to put the government in the insurance business with a ``State opt-out,'' whatever that might mean. I am a former Governor. I am wondering, Does that mean we can opt out of the taxes as well as the benefits? So the Senator from Arizona is right. We are here. We are ready to go to work. We are anxious to read the bill, but it is being written behind closed doors.

If I could ask one more question of the Senator from Arizona, who is giving a lot of time to this discussion. I thought this health care debate was supposed to be about reducing costs--the cost to the government and the cost to people buying premiums. Whatever happened to that goal?

I thank the Senator from Arizona. All of this got started because the Senator from Rhode Island had complained that the Democratic leader had to cut off debate 32 times, and my response was that was nothing to brag about; that is what the Senate is for. That is how the Founders created it.

I appreciate the Senator from Arizona pointing out that in the case of unemployment compensation, we all want to extend the benefits. We think we may have a way to do that in a way that creates more jobs rather than taxes on jobs. In the case of health care, yes, we want to go slow enough to be able to do two things: Read the bill, know what it costs, because we want to make sure that if we pass a health care bill, we are not the Congress of higher premiums, higher taxes, Medicare cuts, and adding to the debt. I think the American people want to make sure we do that as well. So I am grateful that we have the Senate. We are always a little more grateful for those rules when we are in the minority, because they protect our rights to represent the people who elect us and to ask us to offer amendments. But the American people have been served very well by a Senate that has different rules and procedures.

Student Loans

I wish to say a word about a subject which has nothing to do with health care and nothing to do with climate change, which is the other subject I have been in hearings on today, but it is a subject that will affect millions of families in America, and that is the question of going to college and student loans.

All of us can imagine the anxious moments in our family lives--and there are a number of them, including when a baby is born or when the daughter goes out on her first date; when someone is sick; when a child goes off to college. But one of the most anxious moments comes just after the first of every year when, in millions of homes across America, students and their parents wait to see if they have been admitted to college and to which college. The next anxiety comes when they turn to the various options they have to see whether they can afford to go to that college.

Fortunately, in America we have the best system of higher education. We not only have the best colleges; we have almost all of the best colleges. We have 6,000 autonomous institutions of one kind or another--public, private, religious, secular, profit, for-profit--among which students may choose. Second, even though prices have been going up, we have bent over backward in this country to try to make it possible for the largest number of Americans to attend college. Seventy-seven percent of Americans who attend college--nearly 20 million--have a Federal grant or Federal loan to help them do that.

So just after January--and I want to paint this picture--in homes across America, we have millions of students, millions of families who are waiting for their college admissions and then will turn to the question of: Can I get some help paying the bills. Specifically, we have 14 million--if next year is anything like last year and the year before--14 million of those students who will be going to college on 35 campuses who will be borrowing $60 million through the Federal Family Education Loan Program--what we call the traditional student loan program.

We have two types of loan programs. We basically have one through two thousand lenders, profit and nonprofit, across the country. For example, we have an organization called Edsouth in Tennessee that is nonprofit. It offers a variety of student loan options to Tennessee students. It has five regional outreach counselors to provide college and career planning, financial aid training, college admissions assistance, and financial literacy. It makes 443 presentations at Tennessee schools through college fairs, guidance visits, and presentations. It works with 12,000 Tennessee students to improve their understanding of college admissions and the financial aid process. Last year, Edsouth provided training to over 1,000 school counselors and distributed 1.5 million financial aid brochures.

The various lending institutions--profit and not-for-profit--are usually in these communities and easy for these 14 million students to get to. There is another group of students--about a fourth to a third in total--who choose to go another route in getting a student loan, called direct lending. They borrow directly from the government. This was set up as a pilot program when I was the Secretary of Education in the early 1990s. It was set up to see whether the traditional student loan program, which is through your local bank or nonprofit, was working right, and what was best for students.

Students and colleges have voted over the years with their practices. For

example, in Tennessee, most Tennessee campuses and most Tennessee students choose the traditional student loan program. At the University of Tennessee, where I was once president, in Knoxville, there are 30,000 students, and 11,000 have a Federal loan. They get that through the traditional loan program, not the government direct loan program. At Maryville College, in my hometown, where my parents went, 824 of 1,100 students have a Federal loan. They get that through the traditional loan program. At Carson-Newman, at Jefferson City, where I am going Friday to help inaugurate a new president, with 2,000 total students, 1,259 have a Federal loan. I can go through each of the institutions in our State. You can see the number of families that any change in the student loan program affects, and if you add the anxiety that comes with receiving your college admission and worrying about whether you can pay the bill--you can see the problem that causes.

The reason I came to the floor is that for those 14 million students--more or less--who, in January, February, and March, would be expected to turn to the traditional student loan program, we are about to have a 14-million car pile-up on the interstate highways of American education because of action taken by the U.S. Department of Education.

The Secretary of Education--a man I greatly admire--has sent a letter to the various schools--3,500 or so campuses--that now use the traditional loan program, and he said you better get ready for the government-run program, and you need to do it because I may not be able to continue to offer the traditional loans.

That is a big mistake. I want to point out the reasons. First, there is not time to switch, even according to a New York Times article.

I ask unanimous consent to have printed in the Record the Secretary's letter to the campuses and the New York Times article.

The Secretary's assistant says it takes at least 3, 4 months for colleges to switch their computers around, so instead of offering aid through a traditional program, they offer it through the government direct loan program. There will be a lot of confusion in January, February, March and April. There is not time to switch.

Second, the Secretary has gotten ahead of himself. The President has proposed a Washington takeover of the student loan program, but this Washington takeover requires congressional approval. We have more than one branch of government in this town. I know the House of Representatives has passed the President's request, but there's one more--the United States Senate has not approved the President's request, and I hope it does not. It is a bad idea.

So I hope the Secretary will write another letter and say I have changed my mind, given the lateness of the situation in the year--we are almost to November--and the fact that it takes up to 4 months for any college to make a changeover, and because most students will begin to receive their college admissions in January and February, et cetera. I hope the Secretary will say I am going to take a little different approach and work with Congress, recognizing that the Congress has to approve this proposal as well.

First, we are going to extend the law that was passed a couple of years ago,

which provides emergency financing to back up all of the traditional student loans that are made. That has worked out very well. The institutions participating have paid large fees to the government and students have gotten their loans. We can extend that another year. It doesn't expire until June.

Second, the Secretary might say that I am going to work with Congress to make some changes in the existing student loan program to make it right. We can talk about ways to do that.

Third, I hope he will say I am going to work with Congress to set up a transition time that is appropriate for any colleges that want to move from the traditional student loan program to the government-run direct loan program.

When time comes for us to debate and act on whether there should be a Washington takeover of student loans, I am going to say, no, there should not be. I have a little history here. I think the American people have had enough Washington takeovers--banks, insurance companies, General Motors, et cetera. The President can argue that he inherited a lot of that. But this takeover is truly voluntary.

Nobody is asking the Secretary of Education to become the banker of the year. I would rather he become the Secretary of the year. I think he could do that. I think he is an outstanding Secretary, one of the best appointees--maybe the best--of the new President. The Presiding Officer is from Illinois, and he knows Arne Duncan very well. I would like to see him reward teachers and setting higher standards, instead of making 20 million student loans every year. I want him to be the educator of the year, not the banker of the year. Deep in his heart, maybe he wishes that as well.

The administration has told us about this latest Washington takeover that is starting next year, and that the nearly 20 million students who want government-run direct loans should all line up at offices designated by the U.S. Department of Education. This will, the argument goes, save taxpayers $87 billion in subsidies that now go to greedy banks. In anticipation, Members of Congress--we--have already spent the $87 billion for more Pell grants, community college improvements, and other new programs. That sounds very good. Banks are punished, students are helped and, most important, Congressmen look real good.

Here is what they have not told you. Your friendly government, for all this, will overcharge you, the student--and use the profit to pay for the new programs that make the Congressmen look good. Yes, those of you who borrow student loans--the 20 million--the Education Department is going to borrow the money at 2.8 percent from the Treasury and loan it to the students at 6.8 percent, and spend the difference on administrative costs and new government programs. That means a student will spend a few more months or years working to pay off the student loan in order to help pay for someone else's education and help the Congressmen's reelection.

There are a few other things the government ought to tell you. The $87 billion isn't real. According to a letter in July from the nonpartisan CBO to New Hampshire Senator Gregg, the savings are closer to $47 billion. If we use the same cost scoring analysis that the CBO required when we passed the Troubled Assets Relief Program, or TARP, the savings I think are less than that, since the government assumes it can make 19 million loans each year for what it now costs to make 4 million loans.

Finally, the government needs to disclose to these 20 million students who are thinking about going to college next year that getting your loan will become about as enjoyable as waiting in line for your driver's license. Today there are 2,000 lenders--banks and nonprofit institutions--competing to offer government-backed students loans at 4,400 campuses. I mentioned earlier the kinds of services they provide. That is all about to change. There will only be one student loan banker under this proposal, the U.S. Secretary of Education. I wouldn't have wanted that job when I was in that position, and I cannot imagine any Education Secretary wanting that job. There will be no competition to make it easier to get your loan.

Imagine 20 million students and families trying to call a Federal call center to make their arrangements to go to college. It is true that during the last 20 years subsidies the government paid to lenders to make student loans were excessive. Congress took steps to correct that 2 years ago. If there is still $87 billion, or $47 billion, in real savings, then the subsidies are too high and we should lower them and give the savings to students, not trick students by overcharging them to pay for more government programs and run up the Federal debt in the process. Seven-eighths of the students who applied for Federal aid using the Free Application for Federal Student Aid had an average loan of about $25,000. Assuming a standard 10-year repayment at 6.8 percent, which is the rate set by Congress, these students would pay roughly $9,400 in interest. But we could use the savings to reduce the interest rate by as much as 1.5 percent--down to 5.3--and those students would pay only $7,100 in interest, a savings of $2,200.

If this Washington takeover goes through, every one of the 19 million-plus student loans made in 2010 should carry this warning label: Beware, your Federal Government is overcharging you so your Congressman can take credit for starting a new government program. Enjoy the extra hours you work to pay off your student loan.

Mr. President, I see my colleague from South Dakota on the floor and my colleague from Nebraska, so I will conclude.

The Secretary of Education should change his mind, withdraw his letter, and work with Congress to extend the temporary law and improve the student loan program and reassure students that they don't have to be anxious about standing in line in January for a loan.

I yield the floor.

Mr. President, could I just interrupt?

Thank you.

To answer my colleague quickly, I think the vote was 87 to 13, or in that general range. Almost all Republicans voted to conclude the unemployment compensation legislation by getting to the process where we could offer amendments and then have a vote on the final passage.

But I would ask my colleague from Tennessee, have Republicans been afforded the opportunity to offer five amendments? How about four amendments, three, two, one? Obviously not. Have Republicans been afforded the opportunity to offer any amendments, I would ask my colleague? Then I have a follow-up question.

Mr. President, if I could further inquire of my colleague, is it not the Senator's understanding that of all of the issues the American people are concerned about today, the No. 1 issue is jobs and economic recovery--how do they get back to work?

When our friends from the Democratic side say: We need to hurry up and extend unemployment compensation, my guess is the vote on that will be overwhelming. I will support it. I am sure my colleague will support it. That is not the question. The question is, Instead of just continuing to extend unemployment compensation for all of the increased number of Americans who are out of work, what are we going to do to put people back to work?

Then I have one other question to ask my colleague. I may not be correct that it is the No. 1 issue in public opinion surveys, but I recall it is pretty high on the list.

Mr. President, if I could further inquire, the first thing we want to do is find out how much this unemployment extension is going to cost. I think the number is about $2.4 billion. The second thing we want to find out is, how is it going to be paid for? I understand it is proposed to be paid for by a continuation of a tax on payroll; that is to say, employers and employees will have to pay a certain percentage of the employee's wage to the Federal Government in order to provide funds to those who are unemployed.

Some of us are concerned if our goal is to put people back to work, to allow

companies to hire more people, that the worst thing we would want to do is impose another tax on hiring, another tax on employees or, to be totally accurate, to extend the existing tax on workers, on payroll, as a way of paying for the extension of unemployment benefits. Perhaps a better way to pay for that would be, for example, to take the $2.4 billion out of unspent and unobligated stimulus funds, which was $780- some billion, half of which is not going to be spent for the next 8 years--or over the period of the next 8 years.

One of the amendments we wanted to offer was not just to extend unemployment benefits but to pay for it in a way that would not harm job creation, as is contemplated under the bill. Am I correct in that?

I know my colleague wanted to talk about student loans, so I will close my point here.

The whole point, when colleagues and friends of ours on the other side of the aisle say: Well, Republicans are just trying to slow this down; the answer is: No, we could have been done with this bill 24 hours ago. All that was necessary was a simple agreement between the majority leader and the minority leader that the minority would get a couple of amendments. One of them is an amendment to say, Let's pay for this worthy cause of extending unemployment benefits in a more sensible way with respect to job creation; at least in a way that isn't going to cost us jobs, to prevent employers from hiring more people. Let's pay for it by taking some of the unobligated stimulus funds that won't be spent for another 6 or 7 years and achieve our goal in that way. But no, no agreement to do that. The majority says no amendments, take it or leave it.

If you ask for amendments, then you are slowing the process down and somehow standing in the way of those who are unemployed. The benefits haven't run out yet. We are going to pass this before the benefits run out. That is not the question. You can either come down here and make a pitch to people to make it sound as though you are trying to help them and the other side is not or you can try to do things the right way. I submit that on this, the right way is to pay for it in a way that doesn't cost jobs because our goal here ought to be to put people back to work.

I would also say that if the majority were serious about getting this legislation completed, they would not in the middle of the process have parachuted onto the floor a bill that around here was called the ``doc fix''--a most unfortunate term--a bill that was going to add $250 billion to our debt in relationship to the reimbursement of physicians who provide Medicare benefits. The minority didn't do that. Republicans didn't do that.

My point is that a week ago we could have had an agreement to conclude work on the extension of unemployment benefits that would have taken maybe 24 hours, maybe 48 at the most. We would have had the benefit of voting on a couple of amendments, which I think are very well taken, directly relating to the subject, germane amendments, but for some reason the majority has not seen fit to permit that to happen.

So as friends around the country consider what is the reason for this being slowed down, I hope there would be a better appreciation of the reason why this has been delayed. A, we didn't ask for the delay. The delay was occasioned by action by the majority leader by, first, going to another bill and, secondly, by filing cloture and, third, by not agreeing to allow the minority to have a couple of amendments.

Finally, I would say I wish we did have that opportunity because I think when we do support this, it will be a better bill by not only taking care of those who find themselves without a job today but helping to find a way to get them back to work, and that ought to be our primary goal.

I thank my colleague for yielding.

Mr. President, if I could comment on that, that is another very important point. I think Americans very much want to engage in a debate about health care reform. I think Republicans are anxious to engage in that debate here on the Senate floor. But, first you have to have a bill. You can't just have a debate on the floor; you have to have a bill you are debating.

We are told there is a bill. It was written in the majority leader's office with some people from the White House and a couple of other Democratic Senators, and then the bill was sent to the Congressional Budget Office to be scored, for a cost estimate to be developed. I know several people have said, Could we see the bill? Could you share that bill so the American people can see what we are talking about here? So far, no luck. No bill. If we are talking about getting this debate going on health care, one would think that we would get the bill written, we would get it out there, we would all get a chance to read it, our constituents would have a chance to understand what is in it and, by the way, know how much it costs.

I ask my colleague from Tennessee, are Republicans doing anything to slow down the bill or making it public or understanding it?

Mr. President, I would say to my colleague, the minority leader yesterday in a press conference talked about this bill that has been written. I am not actually even sure it has been written. Obviously, we have never seen it. All the majority leader has chosen to talk about publicly is the so-called public option. So maybe that one feature of it has been written.

My point is it isn't Republicans who are slowing anything down. As far as this health care debate is concerned, I think we are very anxious to engage in that debate now. As my colleague from Tennessee pointed out, we are not going to be in debate on a bill which is going to raise taxes, raise premiums,

cut benefits under Medicare, increase the deficit, reduce the quality of our health care, and I am not going to vote to begin work on that kind of a bill, but I certainly will vote to begin work on a bill which meets the primary objective.

There are two primary things we need to try to resolve. One is to make sure we could get insurance to about 18 million Americans who can't afford it and don't have it, and the other is to keep premiums from going up. As the Senator from Tennessee pointed out, under the legislation that came out of the Finance Committee and out of the House of Representatives, insurance premiums go up more than they otherwise would have--according to who? The Congressional Budget Office, the nonpartisan entity that we all ask to analyze these things. There are many other studies that came to the same conclusion.

So I am not anxious to begin working on a bill that does those things, but so far we haven't seen any bill.

Well, I would say to my colleague, something happened to it on the way to the Senate, I guess. Because, first, the bill is going to cost somewhere between $800 billion and $1 trillion. That is obviously money that isn't being spent today that will be spent tomorrow. I don't know of any American who believes you can have a $1 trillion new government program and not add to the debt, but we are told: Wait for the details; we will show you.

There is only one way to make sure it doesn't add to the debt: Raise taxes so much that you cover the costs of it. Then that gets to the other half of the equation. What about for the American people? Are we going to be better off? No. It turns out we are going to have our taxes increased by $400 billion, Medicare cut by almost $500 billion--by the way, if it is ever cut. There is a question about whether we will ever achieve those savings; we never have in the past--in which case the bill is then out of balance by $500 billion; $500 billion in debt. So either there is going to be a big debt there or seniors are going to see their benefits lost.

But I wandered off the point. My colleague was asking, Wasn't the exercise here to reduce costs. Yes. And what will the bills do? It will increase costs for the Federal Government so, therefore, the taxpayers. It will increase costs for all Americans in the form of higher taxes, some imposed directly on us. For example, if we don't comply with the government forcing us to buy insurance, the Congressional Budget Office says other taxes will be passed directly through to us. For example, there is a tax on the manufacturers of medical devices. If you have an angioplasty or some kind of heart problem and they put a little stint in there, one of those very high tech items, that is going to get taxed. Why should you be taxed on something that makes you well? I can't understand that. But in any event, the tax is first on the manufacturer and it will be passed on to the consumer, so increased taxes.

Finally, my colleague asked about premiums. According to CBO, the premiums will go up over what they otherwise would have been. The Oliver Wyman study that I think is very credible on this said the average would be $3,300 per year per person. In my State of Arizona, it was over $7,000, an increase in insurance premiums over what it otherwise would be. When Americans see that, they are going to say, Where is the reform? This is a lot worse than it was before.

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

Madam President, I wish to talk for a moment about health care

since, hopefully, one of these days we will be able to begin a debate on a piece of national health care legislation. I wish to make it clear that Republicans support sensible health care reform, but we believe the bill the majority will bring to the floor could create a whole new set of health care problems. We don't have the specifics yet, but I think we can be sure that certain things are true.

First, the bill is a Washington takeover of health care that will raise taxes, cut Medicare by nearly $\1/2\ trillion or more, and increase premiums as new taxes on the insurance industry and medical device manufacturers are passed on to consumers. This much we know. Before any bill is considered and as we debate the legislation, we think it is important to remember Americans have some rights in this process.

They have the right, for example, to have access to all the specifics of the bill and to have time to weigh it and to give us their reactions, their concerns. Let's not forget we function as a result of their consent, the consent of the governed.

Americans also have the right to know what the legislation is going to cost them and their families, including what it will cost their children and grandchildren 10 or 20 or 30 years from now. They have a right to know what it will cost the Treasury and how much debt will have accrued. By the way, if Medicare is a model for the new Washington-run health care program, how can anyone believe it is going to be deficit neutral? In fact, I asked people at a townhall meeting: How many people here believe you can have a $1 trillion health care bill and not add to the national debt? Not a single hand, of course, was raised.

We also have the right to know about the unintended consequences of the bill. A lot of my constituents are concerned because of a Lewin Group prediction that 119 million people will end up on the Washington- run insurance plan. That is of great concern to them, among other things. They also are concerned this will interfere with their sacred doctor-patient relationship. They have a right to have their concerns taken seriously.

I think one of the guarantees we need to give to our constituents is that the President can keep his pledge not to raise taxes on the American people, as he pledged not to increase taxes by one single dime on middle-income Americans. Yet as we read the legislation that has come out of the various committees, taxes are raised on Americans.

Republicans will insist on these protections, these guarantees for our constituents: protections from increased premiums, from Medicare cuts and from increased taxes and, perhaps most importantly, protection from rationing of health care, the delay and denial of care that comes from things such as Medicare cuts of $\1/2\ trillion.

We support legislation that features cost-saving measures Americans can support, things such as medical liability reform. But what we want to ensure is that our constituents do not have to suffer high taxes, high premiums, a bill that cuts Medicare and ends up rationing their health care. Americans deserve better.

Mr. President, I ask unanimous consent that at the conclusion of my remarks, the Senator from Pennsylvania, Mr. Casey, be recognized.

Mr. President, I thank him for his courtesy in allowing me to precede his remarks this evening.

Health Care Reform

A little more than a year ago, President Obama said:

I can make a firm pledge. Under my plan, no family making

less than $250,000 a year will see any form of tax increase.

Not your income tax, not your payroll tax, not your capital

gains taxes, not any of your taxes.

We have not seen the bill yet--the bill written in the majority leader's office--but it is probably fair to assume that the Finance Committee bill will cover most of the tax provisions.

So how does the President's commitment fare under the Finance Committee bill? It turns out that the bill will raise your taxes. In fact, it will raise them in several ways.

First, the Finance Committee bill would levy a host of new taxes on millions of Americans--and I am not just talking about the wealthy--in fact, primarily on middle-income Americans who I think will tell you they already have enough taxes to worry about.

Let me discuss the specific elements of this bill. The first one is on taxing flexible savings accounts. Under current law, employees can make contributions to flexible spending accounts. Many middle-income families enjoy the benefits of these accounts which allow them to set aside tax-free

income for their medical expenses. In fact, the Employers Council on Flexible Compensation estimates that the median income for those 35 million Americans who have an FSA is $55,000. The bill would limit their contributions to $2,500. So the less they can contribute, the more their taxable income rises. The total cost for taxpayers? It is $15 billion over 10 years.

The Finance bill would also tax many Americans through their insurance plan by imposing a 40-percent excise tax on certain high-cost plans. So while another part of the bill taxes you if you don't buy insurance, this provision will tax you if you buy too much. So tax No. 2, if you don't buy insurance; tax No. 3, if you buy more than Washington thinks you should.

Tax No. 4, Americans who suffer catastrophic illnesses and the chronically ill would face a harmful change in the IRS Code, the Tax Code. Currently, catastrophic medical expenses are deductible if they exceed 7.5 percent of income. The bill would raise that threshold to 10 percent. Mr. President, 87 percent of Americans who would be hit by this tax earn less than $100,000 a year. Seniors, who already face hardships through Medicare cuts, would be exempt from this tax for only 4 years.

In addition to raising these four taxes, the bill taxes insurance which would be passed on to everyone who buys health insurance. Specifically, the bill would impose an annual $6.7 billion so-called fee on the insurance industry. The entire amount collected by this tax: $67 billion over 10 years would be passed on to patients in the form of higher premiums, according to the Congressional Budget Office. That is tax No. 5.

The bill would also impose a new tax on medical devices, $40 billion over 10 years. The entire cost of this tax, too, would be passed on to patients in the form of higher premiums, according to the CBO.

The medical device tax will be assessed against thousands of products such as contact lenses, stethoscopes, hospital beds, artificial heart valves, and advanced diagnostic equipment, thereby increasing costs for consumers, physician practices, hospitals, and the sickest patients who require the most care.

There is serious, bipartisan concern over this provision. But the last time we looked, it is still in the bill.

So here are six ways Americans earning less than $250,000 will be taxed, contrary to the President's promise. Some are direct taxes, such as the IRS tax if you don't buy the exact insurance policy Washington says you must. Others are indirect but a tax nonetheless because the first target, be it the device manufacturer or the insurance company, will, according to the CBO, pass it on directly to you.

The bottom line, Mr. President, is that the tax provisions in the bill will, in fact, violate a fundamental promise President Obama has made about health care--not to raise taxes on middle-income Americans. The American people have a right to expect some guarantees from Washington. Keeping the President's promise on tax increases is one of them. But that is not the direction in which this bill is moving. This bill would increase taxes on working families, seniors, and the chronically ill by more than one-half trillion dollars over 10 years. Republicans have better ideas, starting with protection from taxes and premium increases. The whole point of health care reform is to make things better for American families. These taxes only make things worse.