A resolution authorizing expenditures by the Committee on Commerce, Science, and Transportation.

Madam President, how much time remains on the Republican side?

Madam President, I ask unanimous consent to consume that 3 minutes and the other 15 minutes allotted to our side on the executive nomination, and when that 18 minutes is up, the remainder be followed by the time on the Democratic side and the nomination be reported.

Madam President, I wished to spend a few minutes on this.

As a physician who cared for Medicare patients for 25 years, I cannot tell you how worried I am about what this bill is going to do to my senior patients. When Medicare was first written, two things were put into the law--very straightforward, very direct. Let me read them to you, for a minute. I hope Americans listen to this. Here is what the law is. CMS is breaking the law today and, with the new Medicare Commission, they are going to break it even further under this bill.

Section 1801 says this:

Nothing in this title shall be construed to authorize any

Federal officer or employee to exercise any supervision or

control over the practice of medicine or the manner in which

medical services are provided, or over the selection, tenure,

or compensation of any officer or employee of any

institution, agency, or person providing health services; or

to exercise any supervision or control over the

administration or operation of any such institution, agency,

or person.

That says that the Federal Government cannot practice medicine. That is what it says.

Section 1802 says this--and this is where it is important for my Medicare patients and everyone out there:

Any individual entitled to insurance benefits under this

title may obtain health services from any institution,

agency, or person qualified to participate under this title

if such institution, agency, or person undertakes to provide

him such services.

Well, what we have in this bill is the gutting of those two foundational principles of Medicare. The first is the Medicare Advisory Commission is going to tell you what you can and cannot have. Here is what we are going to see: You will choose what I tell you to choose if you are a Medicare patient.

Not only do we have almost $500 billion in cuts to Medicare, under the auspices that we have to control entitlement spending; not only are we taking away plans from people who are very satisfied with what they have today, but we have enhanced, and will enhance, the ability of the Federal Government to practice medicine.

My colleagues on the other side of the aisle, who have never practiced medicine, who know the legalese but don't know the consequences of right now the rationing of Medicare on drugs such as Epigen and Neupogen--you see, Medicare has decided when oncologists can use those drugs. They have taken a

blanket position, although they have released it somewhat. But what it says is this--I will give you a patient who has breast cancer. She is 67 years old. She is being treated for breast cancer. She becomes anemic and neutropenic. That means her white blood cell count, her ability to fight infection goes down.

We have wonderful drugs that raise the white blood cell count and raise the red blood cell count. But Medicare, in its obvious wisdom of practicing medicine, has told the oncologists when they can and cannot use it. That is fine for 75 percent of the patients, but it totally ignores the other 25 percent of the patients who happen to have complicating factors, such as congestive heart failure or if they become anemic under breast cancer chemotherapy and have congestive heart failure as well. The government says you cannot have erythropoietin at this level of hemoglobin regardless of whether you have congestive heart failure.

What happens is the practice of medicine out of Washington or Maryland, more specifically, determines who can and cannot have a drug; in this case, erythropoietin.

What is the consequence of that? The consequence is that the patient did not die of breast cancer; she died of congestive heart failure that could have easily been treated had we not had medicine practiced by CMS denying the ability of the physician to give the patient exactly what she needed when she needed it.

We are starting down that road with this bill--aggressively starting down that road--because the Medicare Payment Advisory Commission, combined with the Comparative Effectiveness Panel will not look at complications and will not look at secondary diseases. They will look at the average.

I want to tell my colleagues, when you are sitting in an office with your doctor, you are not average. You are you, and you are a specific individual with a set of factors that nobody else has. The judgment in the practice of medicine cannot be done by an insurance company or CMS at a distance without them having a hand on the patient. They never have their hand on a patient.

The whole art of medicine, which is 40 percent of getting people well, is the knowledge and training and experience and gray hair that comes with looking at the total patient, being one on one, not having the government between the doctor and their treatment of a patient.

What this bill does--this bill is a lie one of two ways. One, it says we are going to take this money out of Medicare and you are not going to notice any difference. That cannot be true. If we take $500 billion or $400 billion-plus out of Medicare, millions of seniors are going to notice a difference in their health care and what they get under Medicare. If we say that is not true, then the only way that is not true is the game that is being played on the financing of this program; that is to say, we are going to cut this money out of Medicare and then with a wink and a nod know we are never going to do it.

The majority leader said yesterday there is nothing more important in this Nation right now than passing health care reform. I differ with that statement. I think 10.2 percent unemployment is a whole lot more important, and finding those people jobs, than passing health care reform. I think a $12 trillion debt is more important to address than fixing health care right now. I think the fact that we have $350 billion worth of waste, fraud, and duplication in the Federal Government every year, and we are not addressing it, is more important than fixing health care right now. I think the fact that our economy is still on its back and people are continuing to lose jobs is more important than fixing health care right now.

I understand the political dynamics, but I also understand very well with my quarter of a century of practicing medicine that what this bill is going to do is destroy the best health care system in the world, and it is going to undermine the security of every senior in this country because what starts as a small couple of things, such as Neupogen and Epogen or like when you can have bone densitometry and whether your osteoporosis can truly be evaluated, CMS has already said how much you can do that, whether your bones are falling apart or not. It is the start of the government practicing medicine.

It is the beginning of our seniors having the government step in between them and their physician in terms of the physician wanting to do what is best for that senior and the government saying: No, I will tell you what you are going to have. I will tell you what you will have.

Thomas Jefferson taught us a lot. He predicted we would have ``future happiness for us if we can prevent the government from wasting the labors of the people under the pretense of taking care of them.''

I want to see a lot of things changed in health care. I want to see true competition in the insurance industry. I want to make sure nobody loses their insurance because they get sick. I want to make sure everybody can get insurance if they are sick. I do not disagree with the basic premise. What I disagree with is moving $2.5 trillion more under government control, which will raise costs ultimately in the health care sector. If it does not raise costs and we are truly going to take this money from Medicare, what it is going to do to our seniors, I have a message for you: You are going to die soon, and they are going to say that is not true, that it is not true.

When you restrict the ability of the primary caregivers in this country to do what is best for their senior patients, what you are doing is limiting their life expectancy. We are saying CMS, the Medicare Payment Advisory Commission, and the Comparative Effectiveness Panel will tell the doctors what they can and cannot do, ignoring the 20 percent of the people for whom that is exactly the wrong prescription. So for 20 percent of our seniors, this bill is going to be a disaster, but it is going to save money because you are not going to be around for us to spend any money on you because the government will have already told us what the treatment plan will be for you. We will decide in Washington through the Center for Medicare and Medicaid Services what you will receive.

They will dispute that, but the people who are going to be disputing that are lawyers; they are not doctors. They have never laid a hand on a patient. They have never put their hand forward on a Medicare patient knowing the consequences of the total patient, the background, the medical history, the sociologic factors that fit, the family dynamics, the past medical history, the family history, and the present state of mind of that patient.

Even more important, what this bill is going to do is divide the loyalty of your doctor away from you. When you go to the doctor today, most of the time that doctor's No. 1 interest is in you and your well- being. When you have this Medicare Payment Advisory Commission and you have this Comparative Effectiveness Panel, what that does is that causes the physician--he or she--to take their eyes off of you. Now they are going to put their eyes on what the government says because the consequences of not doing what the government says will ultimately result in some type of sanction.

Do we want physicians to be patient-centered and focused on their patients or do we want physicians to have their eye on the government and half of an eye on the patient? Which do you think is going to give us the best care? Which do you think is going to give us the greatest quality of life? What is going to give us the greatest longevity with the greatest quality of life? Is it the government practicing medicine, or is it the trust that has been developed through years between a patient and a doctor to do what is in the best, long-term interest of that patient?

I cannot tell you the number of people who die from the CMS regulations on Epogen for oncologists. But there were hundreds-- hundreds--because Medicare never looked at the patient; they looked at dollars.

As we go forward in this debate, what I want seniors in America to know--and I am fast approaching Medicare age; I am 3 years from it--I want them to know the key thing they are going to lose in this bill is the loyalty and primacy of their physician thinking about them. We are going to divide that loyalty to where the physician is going to be looking at the government. If you think that is not true, just look at what has happened so far when CMS

has decided to start practicing medicine.

In the HELP Committee, I offered an amendment to change the language so there would be absolutely a prohibition on rationing care and directing the care from Washington. It was rejected out of hand-- rejected out of hand. Not one of my colleagues on the other side of the aisle voted to prohibit rationing of health care.

Why would they do that? Because the ultimate intention through the Comparative Effectiveness Panel is to ration care. It is to ration the care. It is to limit the amount of dollars we spend and never look at the individual patient.

If we think about the Medicare cuts in this bill, we are going to take $135 billion out of the hospitals. Do you think seniors will ever notice that? I do. I think when you ring your button and you are hurting and you need pain medicines or you need to go to the bathroom, the time it takes for somebody to get there will not be sufficient. What will happen is you will wait. You will have a complication. If you have acute shortness of breath and press the button, the available nurses will not be there. There will be a consequence to cutting $135 billion from payments to hospitals in this country.

We are going to take $120 billion out of the seniors--the one in five seniors who now have Medicare Advantage. I agree, it is more expensive than Medicare. It needs to have some cost containment through competitive bidding, but we should not be decreasing the services, which is exactly what is going to happen. If you are a senior on Medicare Advantage, you are going to lose benefits you now have. You are going to lose them.

One of the ideas of Medicare Advantage was preventive services. One of the things that improved the care in rural America was Medicare Advantage. Yet we are going to take that away. The vast majority of the benefits we are going to cut in half.

We are going to take $15 billion from nursing homes. That may or may not be appropriate, but the way to do that is through a competitive experience based on quality and outcome rather than some green-eyeshade staffer saying we can take $15 billion out of Medicare from payments to nursing homes.

One little secret that is not in this bill, that has not been addressed in this bill, is the estimate by a Harvard researcher that there is $120 billion to $150 billion a year in fraud in Medicare alone. HHS admits to $90 billion. We know it is well over $100 billion a year. Cleaning up the fraud in Medicare would pay for a lot of health care for a lot of folks in this country. There is $2 billion in this whole bill to clean up the fraud.

Why would we not fix that first? Why would we take money from Medicare to create a new program when in fact we are wasting 10 to 15 percent?

I will close with this remark. If you are a senior and you are on Medicare, you better be afraid of this bill. I don't come to the floor and say that very often, but your health care is totally dependent, in terms of being decreased by this bill.

I yield the floor.

Mr. President, if I might respond.

The plan is, women colleagues will be coming to the floor. As they come, I will yield to them, until Senator Mikulski gets here, and then she will yield the time, if that is all right.

Mr. President, before I start, I want to say to my colleague from Connecticut how much I appreciate his work and the work of Senator Baucus and Senator Reid. What a remarkable moment we have here.

When I go home--and I was home for the holidays--people are urging us to get this done. They know their biggest chance of going into bankruptcy is a health care crisis--62 percent. They know, as my friend Senator Dodd has said almost every day of this debate, every morning 14,000 people lose their health care. They know if we do not intervene with a good bill, their premiums--in my home State, I say to the Senator--will be 41 percent of their income, the average income, by 2016.

Can you imagine? That is unsustainable. For people who say: Why don't we address the economy instead of health care, let me say what happens to my constituents if they have to pay 41 percent of their income for premiums. Even if they have a good job, I say to my friend from Connecticut, they cannot make it. So the status quo is cruel, and it is particularly cruel to women.

Amendment No. 2791

Mr. President, I am proud to support the Mikulski-Harkin- Boxer amendment to improve preventive health coverage for women. The Mikulski amendment addresses this critical issue by requiring that all health plans cover comprehensive women's preventive care and screenings--and cover these recommended services at little or no cost to women. These health care services include annual mammograms for women at age 40, pregnancy and postpartum depression screenings, screenings for domestic violence, annual women's health screenings, and family planning services.

The preventive services covered under this amendment would be determined by the Health Resources and Services Administration to meet the unique preventive health needs of women. HRSA is an agency within the Department of Health and Human Services. HHS Secretary Kathleen Sebelius has already said that ``Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today.'' The Secretary made clear that recommendations by the U.S. Preventive Services Task Force ``do not set federal policy and they don't determine what services are covered by the federal government.''

This is not the first time that experts have disagreed about this issue. I have been in this battle before, with Senator Mikulski, who called a hearing with all of the women Senators in 1994 where I insisted that routine mammograms for women over 40 must be covered. And thank goodness we fought back then, and in 1997 and in 2002 when this issue was raised again and again. Since 1991, the death rate from breast cancer has been reduced by over 20 percent.

According to a 2007 Partnership for Prevention report, 3,700 additional lives would be saved each year if we increased to 90 percent the portion of women age 40 and older who have been screened for breast cancer in the past 2 years. The most recent data show us that approximately 17 percent of breast cancer deaths occurred in women who were diagnosed in their forties. That is why the American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Mammograms are still the most effective and valuable tool for decreasing suffering and death from breast cancer. The Mikulski amendment will ensure women are able to get access to this and other lifesaving preventive services at no cost.

The underlying bill introduced by Senator Reid already requires that preventive services recommended by the U.S. Preventive Services Task Force be covered at little to no cost. These recommendations already include some women's preventive services such as osteoporosis screenings.

But they do not include certain recommendations that many women's health advocates and medical professionals believe are critically important, such as screenings for ovarian cancer--a disease that will claim the lives of nearly 15,000 women this year. We know that when ovarian cancer is diagnosed early, more than 93 percent of women survive longer than 5 years.

Women are often the decisionmakers for their families when it comes to health care. But women too often put the health needs of their family members and their children ahead of their own.

By passing this amendment, we are saving the lives of countless mothers, daughters, grandmothers and sisters who would otherwise forgo preventative health care because of high copays and expensive deductibles.

I would like to share with my colleagues a story from a doctor in my home State of California, William Leininger, that drives home the importance of this amendment:

In my last year of residency, I cared for a mother of two

who had been treated for cervical cancer when she was 23. At

that time, she was covered by her husband's insurance, but it

was an abusive relationship, and she lost her health

insurance when they divorced.

For the next five years, she had no health insurance and

never received follow-up care (which would have revealed that

her cancer had returned). She eventually remarried and

regained health insurance, but by the time she came back to

see me, her cancer had spread.

She had two children from her previous marriage--her

driving motivation during her last rounds of palliative care

was to survive long enough to ensure that her abusive ex-

husband wouldn't gain custody of her kids after her death.

She succeeded. She was 28 when she died.

That is not a story that should be told in the richest nation in the world.

As I said, I am so proud to support the Mikulski-Harkin-Boxer amendment to improve preventive health care coverage for women. Here is why. It is a fact that women are increasingly delaying or skipping altogether preventive health care, and they are doing it because of costs.

I read a statistic done by a nonpartisan group that said about 39 percent of men are delaying going to a physician to check on a problem. But over 50 percent of women are doing that either because they do not have health coverage or they are fearful of the copay. So we could sit here and do nothing--that is the easy thing to do: Scare people, do nothing--or we could step to the plate, save Medicare, which is very important to save, and that is what this bill does. Because we say we are not going to spend money on waste, fraud, and abuse. We are going to spend money on health care for our people.

And to believe that my friends on the other side are the ones who are going to save Medicare? You just have to read history. Senator Dodd explained it; Newt Gingrich saying: Let Medicare wither on the vine; Bob Dole, our friend, who said, at the time of his Presidential campaign: I fought against Medicare. It was a failure.

Well, if you ask our seniors, I think they are the group most pleased with their coverage. It is not perfect, but it is critical, and we save it here. We extend the life of Medicare.

So here we are in a situation where many women are delaying going to the doctor, getting their preventive services, and the Mikulski amendment addresses this critical issue. It requires that all health plans cover comprehensive women's preventive care and screenings, and cover them at little or no cost.

The reason this is so important is--first of all, in the HELP Committee, under Senator Dodd's and Senator Kennedy's leadership, this piece of the package was in the bill because Senator Mikulski and others pushed so hard to get it placed into the bill.

Mr. President, I would ask my friend from Maryland, Senator Mikulski, if I could complete my remarks and then give the floor over to her?

Mr. President, I thank the Senator.

I am so proud to work with Senator Mikulski. I say to the Senator, we worked on this issue over the years. I just asked my staff to go back and look at the first time we teamed up to ensure that women get mammograms at age 40. That was in 1994. Then, again, over the years, every 3 or 4 years, this whole notion would rear its ugly head: Well, women can do without mammography. The question I have is, What is going to replace it? They would keep trying to take away our tools of self- examination and mammography. We know if you look through the years--and Senator Mikulski and I are proud of a lot of the work we do, but this goes right at the top of the list--we know mortality for breast cancer is way down since the early 1990s. It is 20 percent down since the early 1990s. We have had to stand our ground to protect women, to make sure they get those services they need, those lifesaving services, at little or no cost.

I would also say the American Cancer Society continues to recommend annual screening using mammography and clinical breast exams for all women beginning at age 40. There are a lot of other very important tests that are included in the Mikulski amendment--very important tests--to deal with cervical cancer and ovarian cancer, finding the markers so we know how to deal with these deadly diseases. To give up the tools we have, to turn it over to some organization that does not report to the Secretary of HHS, makes no sense.

What my friend has done with her amendment is to make sure the group that decides this is under the jurisdiction of the HHS Secretary. We know the HHS Secretary has already said she wants to make sure women, starting at age 40, get those mammograms.

I am going to close by reading from an article in the March 10, 1994, San Francisco Chronicle. It says:

Joining what became a phalanx of six female Senators

staring down at federal health officials Boxer said she will

insist that routine mammograms and a host of other women's

health needs be part of any new nationwide benefit package.

The article goes on. It is very clear. What I said at the time is:

After all of these years of women being told it is crucial

by age 40 to get a baseline mammogram, now to have this

tremendous confusion hit us is very disturbing.

Well, it was disturbing on March 10, 1994, when I first got involved in this issue. It was disturbing when Senator Snowe, 3 years later, had us pass S. Res. 47 which said this is our only tool. Let's do it. Thank goodness we have now in this body women and men who get the fact that we refuse as women to be stripped of the only tools we have. Making all of these important tests part of this package is going to save lives. It is going to save money. It is going to mean our families can breathe a deep sigh of relief out there.

So I wish to thank Senator Mikulski for her leadership on this issue and to always stand right at her side on this issue of mammography. We also worked on standards for mammography. Remember that one? It was the deregulation fever that hit the Republican side. They wanted to take away the regulations for mammography, roll them back. We fought the fight, and we will continue to fight the fight.

So thank you very much. I strongly support this amendment.

I yield the floor for my friend, Senator Mikulski.

I thank the Senator from Tennessee. Very definitely we are hearing from seniors in Idaho who see through this. It is very clear to the

folks in Idaho that what we are seeing is a proposed massive growth of the Federal Government by over $2.5 trillion, when fully implemented, that is to be funded on the backs of American taxpayers and senior citizens through cuts in Medicare. In fact, in addition to those who have contacted me who are seeing their health benefits lost, I have also been contacted by a number of the providers. We are talking about those who are in home health care or hospice health care, skilled nursing facilities or hospitals and the like.

They make a very interesting point. Their point is that not only will senior citizens--in Medicare Advantage in particular--literally be losing their benefits dramatically, but that other senior citizens who are in traditional Medicare will also be losing access and quality of care. How is that the case? We know from the details of this bill that we are going to see major cuts in hospice care, home health care, skilled nursing facilities, and hospitals.

The points made to me by those providers are that they have already gone through a series of very deep cuts, cuts to the point that in Idaho for home health care, we have lost something like 30 percent of our facilities already. The way one of them explained to it me was that if you reduce the compensation we are receiving, then we have to reduce something in our budget. He said: We can't just start taking bricks off of our buildings. What we will end up having to do is to reduce personnel. That would be the nurses and the doctors and the other care providers who are there to provide support for these individuals. We will have to reduce the number of rooms we operate or the facilities we provide. In the end, there will be a reduction of services and access available to senior citizens, including a reduction in the quality of the care they are able to be provided.

Obviously, it will come from cuts in Medicare or increased taxes or simply more debt on the Federal level.

The Senator raises a very interesting point. This question of fixing the compensation rates for physicians in Medicare is a huge question, one which we have been fighting for for a number of years to try to find a solution to, as each year we delay the expected cuts that will happen. I have talked about this factor in the context of being a budget gimmick in this bill. What do I mean by that? Those who say this bill reduces the deficit are able to say so only because it has about $500 billion of new taxes, about $500 billion of Medicare cuts, and a number of budget gimmicks that delay the implementation of the spending side of the bill or, in this case, don't even include at all one of the major expenses that needs to be accommodated, and that is the fix for physician compensation. If any of those things were not in this bill, this bill would drive up the deficit tremendously.

What we are going to see, in addition to these fiscal impacts on the Federal Treasury in terms of huge increases in the debt or huge increases in more taxes, even more than we are talking about with this bill, is we are going to see the very real potential that access to medical care for seniors will be again reduced because of this factor.

Let me give a couple of statistics. In their June 2008 report, the Medicare Payment Advisory Commission, or MedPAC, said that 29 percent of Medicare beneficiaries who were surveyed were looking for a primary care physician and had trouble finding one to treat them. In other words, about 30 percent of Medicare beneficiaries today are having trouble finding a physician who will take a Medicare patient. That is before the $465 billion of cuts and before simply not including physicians at all in this legislation.

A 2008 survey by the Texas Medical Association found that only 58 percent of the State's doctors took new Medicare patients, and only 38 percent of the primary care doctors accepted new patients. Again, it is an example from MedPAC and from one State that indicates what we know is happening around the country; namely, that doctors in increasing numbers are no longer taking new Medicare patients, just as they have been doing with Medicaid patients for years. Yet we see these massive cuts to Medicare being proposed that will have the same impact on hospice care and home health service and skilled nursing facilities and hospitals, and we see that doctors are not even included at all, meaning they are projected now to receive major reductions. I think it is over 20 percent reduction in their compensation for taking Medicare patients.

The solution here to establishing a massive new Federal entitlement program is not to cut Medicare. I want to repeat something both the Senators from Arizona and Tennessee have already said that is critical. Reducing the Medicare budget by $464 billion, by any number, is something that has been encouraged in terms of trimming the growth path for Medicare. That is something this Congress has looked at in the past. But never was it intended by those who made these projections about needing to control the spiraling cost of Medicare that we address the fiscal circumstances in Medicare with the intended purpose of creating another new, massive Federal entitlement program that will grow the Federal Government by over $2 trillion--we talked about the numbers; the full 10-year period is $2.5 trillion--and leave Medicare with these dramatic cuts, this loss of service and loss of benefits to the recipients, while they see this new government growth with a new government program. That was not in the mind of anybody who was asking us to deal with the solvency issues on Medicare, and I don't think it was in the mind of anybody who asked that we have some kind of health care reform to deal with the rising cost of premiums.

Mr. President, how much time remains?

Thank you, Mr. President. I wish to conclude with our time this morning by focusing on the larger picture a little bit, as my colleague from Tennessee has done in his concluding remarks.

When you ask Americans whether they want health care reform, the vast majority would say yes. When you ask them what they mean by that, the vast majority in the polls and in my personal experience are saying: We want to see the spiraling costs of health care and our health insurance brought under control and reduced, and we want to see increased access to quality health care for those who do not have access today and for those who have limited access today.

This bill fails on those two central points. What this legislation does, instead, is increase the size of government by $2.5 trillion of new Federal spending, establishing massive new Federal controls over the economy, and even creating a Federal Government insurance company. It increases taxes by about $500 billion, and not just on the so-called wealthy. The vast majority of these taxes is going to squarely hit those who President Obama said would not be hit: those who make less than $200,000 a year and, frankly, all the way down the income chain.

It cuts Medicare by $464 billion. It puts a major new unfunded mandate on our States, which are already struggling in their fiscal budgets. As my colleague indicated, it causes the price of insurance premiums to go up for the individual market, to go up in the small group insurance market, and to be basically unchanged in the large insurance market, according to the CBO study.

By the way, one of the things that is not pointed out in that CBO study very much is in that large market, which it says will be the only part of the market that does not see insurance rates go up, one of the reasons is because their health care will go down. In other words, there is a tax on these larger, high-cost insurance premiums that is going to be either passed through and cause their insurance to go up or will be avoided by reducing the cost of their insurance and reducing coverage of the benefits in these policies. So one way or the other, all Americans are going to see their health care premiums go up or, in the large groups, see their health care premiums be held the same by reducing the quality of the insurance they have.

If you go back to those two reasons Americans wanted health care reform, did we see premiums go down? No. Did we see increased quality or increased access to care? Well, there are some who are going to get a subsidy in this program for this new massive Federal program. But at what price? Mr. President, $2.5 trillion, $464 billion of cuts in Medicare, the establishment of a major new government program that would essentially be funded on the backs of massive new tax increases, massive Federal tax increases, and Medicare cuts, and in the end we will still be in a system in which we are seeing spiraling increases in health care costs. To me, that is not the kind of reform we need.

My colleague from Tennessee indicated there are a number of reforms on which we can find common ground that will reduce health care costs. There are a number of reforms on which we can find common ground that will help us to increase access to quality care. That is where our focus should be. That is why I stand here today in support of my colleague John McCain, his motion to commit this legislation to the Finance Committee. As was indicated, it could be done in 1 day, to simply remove the Medicare cuts that are contained within it. Let's fix that part of this bill, and then let's work forward.

I see my time has expired. I encourage this Senate to focus closely on the legislation and to let us work together in a bipartisan fashion rather than speeding ahead and trying to pass legislation that has not had the opportunity for this kind of bipartisan effort to develop a good work product for the American people.

I congratulate the Senator from Arizona on his analysis of the Medicare cuts. I heard the Democratic leader talk about figures and how we have some figures and the Democrats have other figures. I agree with him. I think someone watching this must think we are on two different planets sometimes, so let me focus in on the figures.

I believe I heard my colleague say to pay for this health care bill over 10 years there would be $465 billion in the Medicare cuts. Where does that figure come from?

I think the Senator from Arizona is right. The President of the United States, in his address to us about health care, and the New York Times, the Wall Street Journal--everyone who has reported on the Congressional Budget Office figures said the same thing. We are going to pay for this bill, which is $2.5 trillion over 10 years when fully implemented, by $465 billion cuts in Medicare.

What Senator McCain in his amendment that we are in support of is saying is, don't cut grandma's Medicare to pay for someone else's insurance. He goes on to say, if you are going to find some savings in waste, fraud, and abuse in grandma's Medicare, spend it on grandma. The reason for that is that the Medicare trustees have said to us that there is $38 trillion in unfunded liabilities for the Medicare Program and that the program will start going bankrupt between 2015 and 2017. According to the Medicare trustees, they say, ``We need timely and effective action to address Medicare's financial challenges,'' and the proposal, if I may say to the Senator from Arizona, who is on the Finance Committee and deeply involved in what we need to do about our Nation's finances, I don't think the Medicare trustees were thinking that the timely and effective action we could take to keep Medicare from going broke was to take $465 billion out of it and spend it on some new program.

I see the Senator from Idaho here. I wish to hear his observations. If there is any issue in this entire health care debate that symbolizes why we on the Republican side want to change the debate to a step-by-step approach to reducing the cost of premiums, it would be the Medicare issue. As the Senator from Arizona said, what we need to do about Medicare is make it solvent as quickly as we can, as effectively as we can. The Senator from Kansas said the other day that the proposal to take $465 billion from grandma's Medicare and spend on it some new program is like writing a check on an overdrawn account in a bank to buy a big, new car. There is a lot of truth to that.

The President said earlier this year something I agree with. He said this health care debate is not just about health care. It is about the role of the Federal Government in the everyday life of Americans. He is exactly right about that. This health care debate, which we are beginning this week, is not just about health care. It is about the stimulus package, about the takeover of General Motors. It is about the trillion dollar debt. It is about the Washington takeovers. It is about too much spending, too much taxes, too much debt. The Medicare provisions in this bill are a perfect symbol of that. That is why Senator McCain is right. What he is saying is, don't cut grandma's Medicare and spend it on some new program. If you can find some savings in the waste, fraud, and abuse of grandma's Medicare, spend on it grandma. Make sure those of us who are older and those of us who are younger and looking forward to Medicare can count on its solvency.

Later this week we will talk more about premiums going up. There was a lot of discussion yesterday because, according to the Wall Street Journal, some health premiums would rise. For people who get their insurance from large employers, this bill won't make much difference. And for small employers, if you get your insurance from a small employer, it won't make much difference. If you are going to the individual market to buy insurance yourself, your premiums will go up, except we are going to get some money from somewhere to help pay part of your premiums, at least for about half of Americans who are in the individual market. Where are we going to get that money? From grandma. We are going to get it from Medicare. So that is what is wrong with this bill. And what is right about the McCain amendment is, it says simply, don't cut Medicare. If we find savings, which we hope we can in Medicare, we should spend it on making Medicare solvent.

I wonder if the Senator from Idaho is hearing from seniors in his State about the proposed $465 billion cuts to Medicare and how they feel about taking that money and spending it to create a new program?

In discussing the Medicare cuts, another provision of the bill which we will be talking about this month and next month as we go through the health care debate is what about the problem of paying doctors and hospitals who see Medicare patients. They get paid about 83 percent of the rate they would be paid if they were seeing a private care patient. Every year Congress has to make an adjustment in something we did a few years ago which automatically cuts the amount of money that we pay doctors who are seeing Medicare patients.

That is a big problem for Medicare patients. Because if the doctors can't be paid, they won't see the patients, and Medicare patients may find themselves increasingly in the condition that Medicaid patients do, low-income Americans who are covered through the State program-- that is our largest government-run program--where they are paid about 60 percent of what doctors who see private patients are paid and about half of Medicaid doctors won't see new patients.

I ask the Senator, does he see anywhere in this bill a provision for the $\1/4\ trillion that will be needed to pay doctors 10 years from now what they are making today? If it is not in the bill, where is that $\1/4\ trillion going to come from? Is it going to come from Medicare cuts, or will it come from adding to the deficit?

Mr. President, how much time remains on the Republican side?

Would the Chair let me know when 4 minutes remain.

The Senator from Idaho will conclude our remarks at that time.

The Senator from Idaho has made an important point, anticipating our Democratic friends will have the next 30 minutes and some other things they may be saying the rest of the day. There was a lot of talk yesterday about the CBO report about the effect of this $2.5 trillion proposal on premiums. Rather than take my word for it, let's go to the news section of the Wall Street Journal of today which has the headline: ``Some Health Premiums to Rise.'' That means going up. That means the cost of your insurance is going up for some Americans.

So my question is, why would we spend $2.5 trillion over 10 years, cut Medicare, raise taxes, and run up the debt to raise some health premiums? I thought the whole exercise was to lower the cost of health care premiums.

The article says:

The analysis released Monday by the nonpartisan

Congressional Budget Office and the Joint Committee on

Taxation--

We are supposed to pay some attention to these outfits as nonpartisan--

painted a more complicated and uncertain picture. It said

people who pay for their own insurance would see a higher

bill, albeit for more generous benefits--

That is the government-approved insurance you are going to be forced to buy.

unless they are lower earners who qualify for a new

government tax credit.

Where is the money going to come from for those subsidies? It is going to come from grandma. It is going to come from Medicare. It is going to come from taxes. And it is going to come from increasing the debt.

Those are facts.

Employees of small firms--

Says the Wall Street Journal--

would effectively see their insurance premiums unchanged--

So for small firms, we are going to spend $2.5 trillion over 10 years, cut Medicare, cut taxes, and run up premiums for millions of Americans, so your insurance will continue to go up at about the rate it already was. Why should we be doing that?

while workers at large firms would see something between

unchanged and slightly lower premiums under the bill--

Compared to what would already happen--

according to the analysis.

We need to change the debate. We need to start over. Instead of this comprehensive 2,000-page bill that is full of taxes, mandates and, as a general effect, raises premiums and taxes and cuts Medicare, we should set a clear goal, reducing costs, and begin to go step by step toward that goal--reducing junk lawsuits against doctors, allowing health care to be purchased across State lines to increase competition, allowing small businesses to combine in health plans so they can offer more insurance to employees at a lower cost.

These three bills I mentioned have been offered and rejected so far by the Democratic majority. We should have more flexibility in health savings accounts, efforts at waste, fraud, and abuse, which are, in effect, Medicaid--the largest government program--and Medicare--the second largest--and more aggressive steps to encourage wellness and prevention.

One approach, the comprehensive 2,000-page bill, Washington-takeover approach, Americans are very leery of. In my respectful opinion, this bill is historic in its arrogance for thinking we could take a system that affects almost all 300 million Americans, 16 percent of the economy, and change it all at once.

Instead, why don't we go step by step to re-earn the trust of the American people? Republicans will be making those proposals on the floor this month and next month and as long as it takes to try to see that we get real health care reform. Cutting grandma's Medicare by $\1/ 2\ trillion and spending it on a new program at a time when Medicare is going broke is not real health care reform.

Mr. President, I ask unanimous consent that during the 30 minutes controlled by the Republicans, we be allowed to engage in a colloquy.

Mr. President, I will begin by making some comments about the amendment Senator McCain, my colleague from Arizona, has filed. This is an amendment that, as the minority leader just said, will protect America's seniors. It will disallow the Medicare cuts this bill includes.

The economist Milton Friedman famously said, ``There is no such thing as a free lunch,'' and that applies to health care as well. There is no such thing as free health care. Someone has to pay. Since this bill is a $2.5 trillion bill, the first question is, Who pays? The first answer to who pays is, it is America's seniors, because about half of the cost of the bill is allegedly paid for by cuts to Medicare.

Let me break down a little bit more specifically than the Republican leader did exactly what that means. This is about $500 billion in Medicare cuts as follows: $137.5 billion from hospitals who treat seniors; $120 billion from Medicare Advantage, which is the insurance program that provides benefits to seniors which will be cut more than in half as a result of this $120 billion reduction; $14.6 billion from nursing homes that treat seniors; $42.1 billion from home health care for seniors; and $7.7 billion from hospice care, one of the most cruel cuts of all.

Obviously, with cut this dramatic there is no way to avoid jeopardizing the care seniors now enjoy, and seniors know this. That is why they have been writing our offices and attending townhall meetings to let us know they disapprove. I quoted from two letters constituents of mine from Arizona sent asking to please not cut their Medicare Advantage Program. This has been called the crown jewel of the Medicare system, and many of them rely on Medicare Advantage for dental care or vision care or hearing assistance they have come to rely on. They are not buying the claims that somehow or other we can make $\1/2\ trillion cuts in Medicare without somehow hurting their care. They know better than that, and they are right. The care they have been promised will be compromised to pay for this new government entitlement under the bill.

Finally, many are wondering what happened to the promise that they get to keep the care they have. We all heard the President say that many times: If you like the care you have, you get to keep it. That is simply not true. There are 337,000 Arizonans who are Medicare Advantage patients. They like what they have. Yet we know, according to the Congressional Budget

Office, that the benefits they have under Medicare Advantage are going to be cut by more than half. They are saying: What happened to the policy I like? I am not going to be able to keep it if this bill passes.

This is why the McCain amendment must pass. If our Democratic colleagues are not willing to protect Medicare, then I cannot imagine how the bill could otherwise be made acceptable since it starts with the commitments that Congress and the President have made to our senior citizens.

Mr. President, I say to my friend from Tennessee, first of all it comes from a reading of the bill. It is very clear in the bill as to how much money is taken from Medicare. The number the Senator from Tennessee just articulated is the correct number.

In addition to that, the Congressional Budget Office and the Joint Tax Committee analyzed the specific numbers. Obviously they were given the numbers in the bill, but the numbers they are using are--I just broke it down into four or five general categories. There are other divisions within that. But as I said, for notional purposes here: $137.5 billion from hospitals; $120 billion from Medicare Advantage. That number might be $118 billion; I am not precisely certain of it, but it is very close. There is $14.6 billion from nursing homes, $42.1 billion from home health, and $7.7 billion from hospice care. If any of our colleagues would like to contest these numbers, I would be happy to be corrected, but I believe those are the correct numbers.

On a new program. That is exactly correct. What the Medicare trustees were saying is, if we can effect cost savings in Medicare, and surely there are some to be had there, they should go to strengthen the Medicare Program itself and not allow it to go bankrupt, rather than it being used to create a new government program.

Perhaps one of the reasons why there are different numbers from one side of the aisle to the other is that sometimes we are not talking apples to apples. We are talking apples to oranges, and perhaps both numbers are correct in their context. The Senator from Tennessee used the number $2.5 trillion when the program is fully implemented. That is a very important statement. The other side will argue it is only $1\1/ 2\ trillion for the first 10 years of the program. That is a correct statement. But it is $2.5 trillion for the first 10 years of total implementation of the program. What is the reason for the difference? For the first 4 years, money is being collected, but very few benefits are going out. The benefits start after year No. 4. So if we take the first 10 years of the program, we are collecting money to pay for it over the entire 10 years, but almost all of the benefits only occur during the last 6 years. Naturally, we have collected more money than we have paid out. But when we take the first 10 years of full implementation, it is as my colleague from Tennessee noted, a cost of $2.5 trillion. That is how sometimes we get somewhat different numbers.

As long as we are clear about what we are talking about, one thing is crystal clear: Whether it is $1\1/2\ trillion or $2.5 trillion, we are talking real money. Somebody has to pay for it. If America's seniors are being asked to pay for half of it, that is not fair to America's seniors, given the commitment we have made to them. That is the point of the McCain amendment. Protect Medicare, protect America's seniors. We can do that with the simple amendment Senator McCain has which is send the bill back to committee--it would only take 1 day--and send it back here without those Medicare cuts in the bill.