Floor Statements

Mr. President, I would like to take a moment today to recognize an armchair explorer who never left the Northeast but brought the world to the United States. In 1809-1810 in the town of Bradford, VT, Mr. James Wilson fashioned the first terrestrial and celestial globes made in the United States. In doing so Mr. Wilson gave to all Americans an invaluable tool that would be used for centuries to come.

A self-taught and passionate cartographer, James Wilson started the first geographic globe factory in Bradford. He achieved such great success that soon after he and his sons opened a second factory in Albany, NY. Wilson Globes set the standard by which all other globes were measured, achieving such perfection that in 1827 he argued to Congress there was no longer a need to import them from abroad.

The accomplishments of James Wilson and his sons are treasured in the picturesque town of Bradford. So much so that the Bradford Historical Society commissioned the Williamstown Art Conservator to repair the historical society's Wilson globe--one of the few remaining in the world. Funds for this project were received from across the Nation. Understandably, the town takes great pride in this small piece of history that they can call their own. Although Mr. Wilson only ever saw a few hundred miles of this great country, he was responsible for bringing the world to most Americans. We applaud James Wilson for the legacy he left us. Furthermore, we applaud the Historical Society and town of Bradford for recognizing Mr. Wilson's remarkable gift and their dedication to preserving the past for our future.

Mr. President, the State of Vermont will celebrate the year 2010 by marking the 250th anniversary of the historic town of Pownal, VT.

In celebrating Pownal, we celebrate a town that has done much more than merely survive the centuries. This bucolic little hamlet represents the strength and progress of our great State through the years.

Since its original charter in 1760, Pownal was built on a rich history that dates back to the divisive years of the revolution. During its earliest days many Pownal residents were stirred to join the Green Mountain Boys to fight for our independence. The fervor demonstrated by the original residents of this town set its course as the bedrock of loyalty and excellence in the State of Vermont.

Today we cherish the historic Mooar-Wright House which is the oldest house in both Pownal and the Green Mountain State. We commend the town's early emphasis on education, with two former U.S. Presidents serving as teachers in north Pownal. Over the centuries this town was a pocket of industrial accomplishment in Vermont. Some of the State's largest cotton and woolen mills were housed in Pownal and later replaced by lime quarries. They helped carry Vermont through years of industrial development and growth. These auspicious achievements, however, also served as a reminder of our capacity for change because the industrial mills in Pownal were singled out for child labor. This documented injustice symbolized the past and put the town on the national map in 1916 when it was depicted on a United States postage stamp to commemorate the passage of the first child labor laws. The heart of the town became its national image in 1946 when the United Nations Bulletin featured a photo of the Pownal Center as ``a picture of peace.'' Throughout the years this town was both the root of tradition and the spark of progress: a balance that few places or populations can claim.

Today, Pownal has developed into a town of more than three thousand. The buildings have grown and the industries have changed, but the ideals remain the same. On its 250th anniversary, Pownal continues to encapsulate the beauty and independence of our State. I thank the residents of Pownal for their contributions to our State's rich and unique history.

Mr. President, it is indeed an honor to represent the State of Vermont and the Town of Pownal and to promote its many successes.

Mr. President, I was proud last night to have voted for the health care bill. The reason is, as Senator Tester indicated, this bill accomplishes a whole lot. Before I go on to talk about what I want to focus on this afternoon, I do want to say there are a number of provisions in the Senate bill I don't support and I hope we can improve in the conference committee by adopting the House language. One is the issue of the public option, with which the Presiding Officer has been so strongly involved. At the end of the day, it seems to me the American people have been very clear. If they are not happy with their private insurance, they want the option of a Medicare type public option. I think we should give them that.

Furthermore, as we look at the soaring cost of health care, we understand that one important mechanism to control escalating health care costs is a public option which provides real competition to private insurance companies that are only concerned about making as much money as possible. I know the Presiding Officer has worked very hard in that effort. I hope we can, in that regard, take the House language which includes a public option.

The other area where I disagree with the Senate and agree with the House is on the issue of taxing health benefits for middle-income workers. The House provision raises substantial funding by putting a surtax on the very wealthiest people in the country, people who received huge tax breaks during the Bush years. That makes a lot more sense to me than taxing the health benefits of middle-income workers.

Having said that, I want to focus on one new provision that was placed in the health care reform bill by Majority Leader Reid. I thank him very much for his strong support for this concept. I also thank Dick Durbin, Chuck Schumer, Patty Murray, the Presiding Officer, and the entire Democratic leadership for their support.

That provision simply provides $10 billion over a 5-year period to the Federally Qualified Health Center Program and the National Health Service Corps. In my view, these two programs are some of the best and most effective public health care programs in the United States. They enjoy widespread bipartisan support. President Bush was a supporter. John McCain, when he ran for President, was a supporter of community health centers. Many Republicans have spoken positively of community health centers, as have virtually all Democrats. The reality, however, is that both community health centers and the National Health Service Corps have been starved for funding for many years. We are finally, in this bill, doing right by them.

I should mention, importantly, that while we have placed $10 billion in the Senate bill, in the House bill there is $14 billion. My strong hope, expectation, and belief--and I have talked to the White House about this and the Senate leadership and House leadership--is that when this bill is finally passed, we will adopt the House language which calls for $14 billion.

Let me tell you why this money is so terribly important. In a few days, the

Senate will be voting on final passage of a historic health reform bill that will insure an additional 31 million Americans who have no health insurance. That is a huge accomplishment. About half of the new people who will get health insurance will be enrolled in an expanded Medicaid Program. While this reduction in the number of uninsured is an essential step in achieving reform, we have to ask a very simple question: If 15 million more people go into Medicaid, where are they going to access the health care they need?

It is no secret that today Medicare is a strained program. When some of my Republican friends make that point, I have to say they are right; it is a strained program. That is why expanding community health centers in the National Health Service Corps is so important.

We talk about the number of people uninsured--a very important number--46 million. But we do not talk about the number of people who every day do not have access to a physician or a dentist on a regular basis, and that number is close to 60 million. These are people who, when they get sick, cannot find a doctor. Where do they go?

Well, several things happen. They may end up going to the emergency room, which is the most expensive form of primary health care we have-- that is where they go--or even worse, they do not go to any doctor at all. What happens is, they get sicker and sicker. Then they go stumbling into a doctor's office, and the doctor says: Why didn't you come in here 6 months ago?

And the person says: I don't have any health insurance. I couldn't afford it.

Then they go to the hospital, and we spend tens and tens of thousands of dollars treating somebody who is now suffering in a way they should not be suffering, at greater expense to the system than should have been the case. Now, what sense does that make?

Let me tell you the worst-case scenario. The worst-case scenario is, they walk into the doctor's office, and the doctor says: It is too late. I can't help you anymore. You should have been in here 6 months ago. I have talked to physicians who have told me about that. I suspect the Presiding Officer has as well. That is why this year we are going to see 45,000 of our fellow Americans die because they do not have health insurance, and they do not get to the doctor when they should.

Now, one of the advantages of the community health care program is that it is an enormously cost-effective program. One study recently reported that $20 billion is wasted every year in this country in unnecessary and inappropriate use of hospital emergency rooms for nonemergency care. When you walk into an emergency room--I do not know about West Virginia--but in Vermont it is about $600. If you get that similar care for a nonemergency-type ailment, the cost is $100. So think about all of the money we save--we save--when we have community health centers expanding all over the country.

One of the issues we have not focused on enough, in my view, in this whole health care debate is the very serious crisis in primary health care in general. The American College of Physicians, in a recent report, warned that the Nation's primary care workforce--which it called ``the backbone of our health care system''--is, in its own words, ``on the verge of collapse.'' That is the American College of Physicians.

Over the past 8 years, for example, the number of family practice residents fell 22 percent, while the overall number of medical residents rose 10 percent. Currently--this is an extraordinarily frightening statistic--only 2 percent of medical students interested in internal medicine intend to pursue primary care as their specialty--2 percent.

This growing crisis was recently underscored in a report by the Association of Academic Health Centers, which warned that the country is rapidly running ``out of time to address what is out of order in our health workforce.''

The good news is that 20 million of those people who live in medically underserved areas are fortunate to live where there are federally qualified community health centers.

Let me explain a bit. What is a federally qualified health center-- which exists in all of our 50 States? It is a center which says: If you have no health insurance, you can walk in and do you know what. You will pay not only for primary health care but for dental care--which is a huge problem all over this country--for mental health counseling, and you will get the lowest cost prescription drugs available in America. And if you do not have any health insurance, you get it on a sliding- scale basis. If you have Medicaid, you are welcome into the center. If you have Medicare, you are welcome. If you have private health insurance, you are welcome into these centers. Currently, these centers serve 20 million Americans in all of our 50 States.

Conceived in 1965 as a bold, new experiment in the delivery of preventive and primary health care services to our Nation's most vulnerable people and communities, community health centers are an enduring model of primary care for the country and are designed to empower communities to create locally tailored solutions that improve access to care and the health of those they serve.

West Virginia centers will be different than Vermont centers, which will be different than California centers because they are designed and locally controlled to serve the needs of the local population.

By mission and mandate, community health centers must see all those who seek their care regardless of health status, income level, or insurance status. If you are rich, if you are poor, you will gain access to these community centers. Nobody is tossed away. Today, these health centers are America's health care home to one out of every four low-income uninsured individuals, one out of every six rural Americans, as well as one out of every seven Medicaid beneficiaries, and one in four low-income people of color. We need to guarantee that as we expand coverage, we expand community health centers as well. They are the one primary care provider who will see those on Medicaid without restrictions.

Furthermore, community health centers already employ so many of the features of what we seek in the medical home model. They provide integrated health care, which is what we are talking about.

A study recently by George Washington University--we are talking about spending money. What is so exciting about this whole concept is you are going to create more health care opportunities for people, and you save money--save money--by keeping them out of the emergency room and out of the hospital. A study by George Washington University found that patients using health centers have annual overall medical care costs that are more than $1,000 lower than those who do not use a health center--$1,000. That translated to more than $24 billion in savings for the health care system last year alone.

We are keeping people out of the emergency room, we are keeping people out of hospitals, and we are keeping them from getting sicker than they otherwise would be. That is why I am so pleased Majority Leader Reid has looked at this track record and concurred that we will guarantee--guarantee--funding of health centers over the next 5 years in order to provide health care to more people and to save money at the same time.

Let me tell you in concrete terms what $14 billion--the amount of money that is in the House bill--will mean to the American people. What it will do is it will increase the number of people who have access to community health centers, from the current 20 million to 45 million over a 5-year period--20 million to 45 million. We are more than doubling the number of people who will be able to walk into a clinic for health care, dental care, low-cost prescription drugs, primary health care--in 5 years going from 20 million to 45 million people.

This funding would create new or expanded health centers in an additional 10,000 communities--10,000 communities--from one end of our country to the other. In some cases, entirely new federally qualified health centers would be established. In other cases, new satellite centers would be created. In Vermont, for example, we have eight community health centers. We have 40 total sites. That is true all over this country.

But can you imagine, Mr. President, that in the United States of America, within a 5-year period, 10,000 new community health centers in this country

would be established? People would not have to go 50 or 100 miles to find access to health care. It would be there in their own community. It would be in urban areas, in rural areas. This is extraordinary.

Now, these community health centers and the growth of these community health centers do not mean much unless we have the medical personnel to adequately staff them.

As I mentioned a moment ago, everybody concludes we have a real crisis in terms of access to primary health care in this country and the number of physicians and dentists and nurses who serve in the primary care area. What this language does, that we have just added, is it would--if we adopt the House numbers--triple funding in a 5-year period for the National Health Service Corps, which provides loan repayments and scholarships to medical students.

For the University of Vermont Medical School, if my memory is correct--this is fairly typical for America--the average medical school student graduates with $150,000 of debt. Well, if you graduate with $150,000 of debt, what are you going to do? You are not going to do primary health care. You are going to go into some fancy specialty and start making a whole lot of money to pay off that debt. But what the National Health Service Corps will be able to do is provide debt forgiveness and scholarships for an additional 20,000--an additional 20,000--primary care doctors, dentists, and nurses. That is a lot of new medical personnel that is going to get out into underserved areas all over America. That is a very exciting thought.

In short, when we more than double, in 5 years, the number of people who have access to community health centers, and within that same period of time we add an additional 20,000 primary health care doctors, dentists, and nurses, we are talking about nothing less than a revolution in primary health care in America--something which we have needed for a long time.

So let me conclude by saying: I want to again thank the majority leader, Senator Reid. I want to thank Senator Durbin, Senator Schumer, Senator Murray, and thank the Presiding Officer and the Democratic leadership for their support of this concept. As you know, this idea was developed back in the 1960s with Senator Ted Kennedy, who developed this concept in the first place. It has expanded, and now we are going to take it a giant step forward and, in the process, I think we are going to make a difference--a real difference--in improving the lives and the well-being and the access to health care of tens of millions of Americans.

Mr. President, thank you very much. With that, I yield the floor and suggest the absence of a quorum.

Madam President, I call up my amendment per the order.

Madam President, I ask unanimous consent that the reading of the amendment be dispensed with.

Madam President, I ask unanimous consent that the amendment be considered as read.

Madam President, may I ask my friend from Oklahoma why he is objecting?

Mr. President, I withdraw my amendment.

Pursuant to the 30 minutes that I----

Madam President, let me begin not by talking about my amendment but by talking about the Republican action that we have seen right here on the floor of the Senate. Everybody in this country understands that our Nation faces a significant number of major crises--whether it is the disintegration of our health care system, the fact that 17 percent of our people are unemployed or underemployed, or the fact that one out of four of our children is living on food stamps. We have two wars, we have global warming, we have a $12 trillion national debt, and the best the Republicans can do is try to bring the U.S. Government to a halt by forcing a reading of a 700-page amendment. That is an outrage. People can have honest disagreements, but in this moment of crisis it is wrong to bring the U.S. Government to a halt.

I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate. I thank Senator Reid for allowing me to try to bring it up before it was obstructed and delayed and prevented by the Republican leadership. My amendment, which was cosponsored by Senators Sherrod Brown and Roland Burris, would have instituted a Medicare-for-all single-payer program. I was more than aware and very proud that, were it not for the Republican's obstructionist tactics, this would have been the first time in American history that a Medicare-for-all single-payer bill was brought to a vote before the floor of the Senate. I was more than aware that this amendment would not win. I knew that. But I am absolutely convinced that this legislation or legislation like it will eventually become the law of the land.

The reason for my optimism that a Medicare-for-all single-payer bill will eventually prevail is that this type of system is and will be the only mechanism we have to provide comprehensive high-quality health care to all of our people in a cost-effective way. It is the only approach that eliminates the hundreds of billions of dollars in waste, administrative costs, bureaucracy, and profiteering by the private insurance companies, and we are not going to provide comprehensive, universal, cost-effective health care to all of our people without eliminating that waste. That is the simple truth.

The day will come, although I recognize it is not today, when the Congress will have the courage to stand up to the private insurance companies and the drug companies and the medical equipment suppliers and all of those who profit and make billions of dollars every single year off of human sickness. On that day, when it comes--and it will come--the U.S. Congress will finally proclaim that health care is a right of all people and not just a privilege. And that day will come, as surely as I stand here today.

There are those who think that Medicare-for-all is some kind of a fringe idea--that there are just a few leftwing folks out there who think this is the way to go. But let me assure you that this is absolutely not the case. The single-payer concept has widespread support from diverse groups from diverse regions throughout the United States. In fact, in a 2007 AP/Yahoo poll, 65 percent of respondents said that the United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the Government and financed by taxpayers.

There is also widespread support for a Medicare-for-all approach among those people who understand this issue the most, and that is the medical community. That support goes well beyond the 17,000 doctors in the Physicians for National Health Care Program, who are fighting every day for a single-payer system. It goes beyond the California Nurses Association, the largest nurses union in the country, who are also fighting for a Medicare-for-all, single-payer health care. In March of 2008,

a survey of 2,000 American doctors published in the Annals of Internal Medicine concluded that 59 percent of physicians ``supported legislation to establish national health insurance.''

Madam President, you might be particularly interested to know that the New Hampshire Medical Society surveyed New Hampshire physicians and found that two-thirds of New Hampshire physicians, including 81 percent of primary care clinicians, indicated that they would favor a simplified payer system in which public funds, collected through taxes, were used to pay directly for services to meet the basic health care needs of all citizens. That is New Hampshire.

In 2007, Minnesota Medicine Magazine surveyed Minnesota physicians and found that 64 percent favored a single-payer system; 86 percent of physicians also agreed that it is the responsibility of society, through the Government, to ensure that everyone has access to good medical care.

But it is not just doctors, it is not just nurses, it is not just millions of ordinary Americans. What we are seeing now is that national, State, and local organizations representing a wide variety of interests and regions support single payer. These include the U.S. Conference of Mayors, the American Medical Students Association, the AFL/CIO, the United Church of Christ, the UAW, the International Association of Machinists, the United Steelworkers, the United Electrical Workers, the Older Women's League, and so many others that I do not have the time to list them.

I ask unanimous consent to insert a list in the Record of all the organizations representing millions and millions of Americans who are sick and tired of the current system and want to move toward a Medicare-for-all single-payer system.

There is also significant support in the House of Representatives for a single-payer system. Together, H.R. 676 and H.R. 1200, two different single-payer proposals, have 94 cosponsors.

And let me say a word about State legislatures that have moved forward aggressively toward a single-payer system. In California, our largest State, the State legislature there has on two occasions passed a single-payer program. The largest State in America passed a single- payer program, and on both occasions it was vetoed by the Governor. In New York State, the State Assembly passed a single-payer system. Among other States where single payer has been proposed and seriously discussed are Ohio, Massachusetts, Georgia, Colorado, Maine, Vermont, Illinois, Wisconsin, Oregon, Washington, New Mexico, Minnesota, Indiana, and New Hampshire.

Why is it that we need an entirely new approach for health care in this country? The answer is pretty obvious. Our current system, dominated by profit-making insurance companies, simply does not work. Yes, we have to confess, it does work for the insurance companies that make huge profits and provide their CEOs with extravagant compensation packages. Yes, it does work--and we saw how well it worked right here on the floor yesterday--for the pharmaceutical industry which year after year leads almost every other industry in profit while charging the American people by far--not even close--the highest prices in the world for prescription drugs.

So it works for the insurance companies. It works for the drug companies. It works for the medical equipment suppliers and the many other companies who are making billions of dollars off of our health care system. But it is not working for--in fact, it is a disaster for-- ordinary Americans.

Today, 46 million people in our country have no health insurance and an even higher number of people are underinsured, with high deductibles or copayments. Today, as our primary health care system collapses, tens of millions of Americans do not have access to a doctor on a regular basis and, tragically, some 45,000 of our fellow Americans who do not have access to a doctor on a regular basis die every single year. That is 15 times more Americans who die of preventable diseases than were murdered in the horrific 9/11 attack against our country. That takes place every year: the preventable deaths of 45,000 people.

This is not acceptable. These horrific deaths are a manifestation of a collapsing system that needs fundamental change.

A number of months ago I took to the floor to relate stories that I heard from people throughout the State of Vermont regarding the health care crisis, stories which I published in a small pamphlet and placed on my Web site. Let me tell you one story.

A man from Swanton, VT, in the northern part of our State, wrote to me to tell me the story of his younger brother, a Vietnam veteran, who died 3

weeks after being diagnosed with colon cancer. At the time he was diagnosed, he had been laid off from his job and could not afford COBRA coverage. This is what his brother said:

When he was in enough pain to see a doctor it was too late.

He left a wife and two teenage sons in the prime of his life

at 50 years old. The attending physician said that, if he had

only sought treatment earlier, he would still be alive.

Horrifically, tragically, that same story is being told in every State in this country over and over again. If only he had gone to the doctor in time he could have lived, but he didn't have any health insurance. That should not be taking place in the United States of America in the year 2009.

Our health care disaster extends beyond even the thousands who die needlessly every single year. Many others suffer unnecessary disability--strokes that leave them paralyzed because they couldn't afford treatment for their high blood pressure, or amputations, blindness, or kidney failure from untreated diabetes. Infants are born disabled because their mothers couldn't get the kind of prenatal care that every mother should have, and millions with mental illness go without care every single day.

In a town in northern Vermont not far from where I live, a physician told me that one-third of the patients she treats are unable to pay for the prescription drugs she prescribes. Think about the insanity of that. We ask doctors to diagnose our illness, to help us out, she writes the prescription for the drug, and one-third of her patients cannot afford to fill that prescription. That is insane. That is a crumbling health care system. The reason people cannot afford to fill their prescription drugs is that our people, because of pharmaceutical industry greed, are forced to pay by far the highest prices in the world for prescription drugs. This is indefensible. There is nobody who can come to the floor of this Senate and tell me that makes one shred of sense.

The disintegration of our health care system causes not only unnecessary human pain, suffering, and death, but it is also an economic disaster. Talk to small businesses in Vermont, New Hampshire, any place in this country, and they tell you they cannot afford to invest in their companies and create new jobs because all of their profits are going to soaring health care costs--10, 15, 20 percent a year. Talk to the recently bankrupt General Motors and they will tell you that they spend more money per automobile on health care than they do on steel. GM is forced to pay $1,500 per car on health care while Mercedes in Germany spends $419, and Toyota in Japan spends $97. Try to compete against that.

From an individual economic perspective, it is literally beyond comprehension that of the nearly 1 million people who will file for bankruptcy this year, the vast majority are filing for bankruptcy because of medically related illnesses. Let's take a deep breath and think about this from an emotional point of view. Let's think about the millions of people who are today struggling with cancer, struggling with heart disease, struggling with diabetes or other chronic illnesses. They are not even able to focus on their disease and trying to get well. They are summoning half their energy to fight with the insurance companies to make sure they get the coverage they need. That is not civilized. That is not worthy of the United States of America.

In my State of Vermont--and I suspect it is similar in New Hampshire and every other State--I have many times walked into small mom-and-pop stores and seen those little donation jars that say: Help out this or that family because the breadwinner is struggling with cancer and does not have any health insurance or little Sally needs some kind of operation and she doesn't have any health insurance, put in a buck or five bucks to help that family get the health care they need. This is the United States of America. This should and cannot be allowed to continue.

One of the unfortunate things that has occurred during the entire health care debate is that we have largely ignored what is happening in terms of health care around the rest of the world. I have heard some of my Republican colleagues get up and say: We have the best health care system in the world. Yes, we do, if you are a millionaire or a billionaire, but we do not if you are in the middle class, not if you are a working-class person, certainly not if you are low income. It is just not true.

Today, the United States spends almost twice as much per person on health care as any other country. Despite that, we have 46 million uninsured and many more underinsured and our health care outcomes are, in many respects--not all but in many respects--worse than other countries. Other countries, for example, have longer life expectancies than we do. They are better on infant mortality, and they do a lot better job in terms of preventable deaths. At the very beginning of this debate, we should have asked a very simple question: Why is it we are spending almost twice as much per person on health care as any other country with outcomes that, in many respects, are not as good?

According to an OECD report in 2007, the United States spent $7,290, over $7,000 per person on health care. Canada spent $3,895, almost half what we spent. France spent $3,601, less than half what we spent. The United Kingdom spent less than $3,000, and Italy spent $2,600 compared to the more than $7,000 we spent. Don't you think that maybe the first question we might have asked is: Why is it we spend so much and yet our health care outcomes, in many respects, are worse than other countries? Why is it that that happens?

Let me tell you what other people will not tell you. One key issue that needed to be debated in this health care discussion has not been discussed. The simple reason as to why we spend so much more than any other country with outcomes that are not as good as many other countries is that this legislation, from the very beginning, started with the assumption that we need to maintain the private for-profit health insurance companies. That basic reality that we cannot touch private insurance companies, in fact that we have to dump millions more people into private health insurance companies, that was an issue that could not even be discussed. And as a result, despite all the money we spend, we get poor value for our investment.

According to the World Health Organization, the United States ranks 37th in terms of health system performance compared with five other countries: Australia, Canada, Germany, New Zealand, and the United Kingdom. The U.S. health system ranks less or less than half.

Sometimes these groups poll people. They go around the world and they poll people and they ask: How do you feel about your own health care system? We end up way down below other countries. Recently, while the Canadian health care system was being attacked every single day, they did a poll in Canada. They said to the Canadian people: What do you think about your health care system? People in America say you have a terrible system. Do you want to junk your system and adopt the American system? By overwhelming numbers, the people of Canada said: Thank you, no thank you. We know the American system. We will stay with our system.

I was in the United Kingdom a couple months ago. I had an interesting experience. It was a Parliamentarian meeting. I met with a number of people in the Conservative Party--not the liberal Democratic Party, not the Labour Party, the Conservative Party, the party which likely will become the government of that country. The Conservatives were outraged by the kind of attacks being leveled against the national health system in their country, the lies we are being told about their system. In fact, the leader of the Conservative Party got up to defend the national health system in the United Kingdom and said: If we come to power, we will defend the national health system. Those were the conservatives.

What is the problem with our system which makes it radically different than systems in any other industrialized country? It is that we have allowed for-profit private corporations to develop and run our health care system, and the system that these companies have developed is the most costly, wasteful, complicated, and bureaucratic in the entire world. Everybody knows that. With 1,300 private insurance companies and thousands and thousands of different health benefit programs all designed to maximize profits, private

health insurance companies spend an incredible 30 percent of every health care dollar on administration and billing, on exorbitant CEO compensation packages, on advertising, lobbying, and campaign contributions. This amounts to some $350 billion every single year that is not spent on health care but is spent on wasteful bureaucracy.

It is spent on bureaucrats and on an insurance company telling us why we can't get the insurance we pay for. How many people today are on the phone today arguing with those bureaucrats to try to get the benefits they paid for? It is spent on staff in a physician's office who spend all their time submitting claims. They are not treating people; they are submitting claims. It is spent on hundreds of people working in the basement of hospitals who are not delivering babies, not treating people with cancer. They are not making people well. They are sending out bills. That is the system we have decided to have. We send out bills, and we spend hundreds of billions of dollars doing that rather than bringing primary health care physicians into rural areas, rather than getting the doctors, dentists, and nurses we need.

Let me give a few outrageous examples. Everyone knows this country is in the midst of a major crisis in primary health care. We lack doctors. We lack nurses. We lack dentists--a major crisis getting worse every single day. Yet while we are unable to produce those desperately needed doctors and nurses and dentists, we are producing legions of insurance company bureaucrats.

Here is a chart which deals with that issue. What this chart shows is that over the last three decades, the number of administrative personnel, bureaucrats who do nothing to cure our illnesses or keep us well, the number of bureaucrats has grown by 25 times the number of physicians. This is growth in the number of doctors--nonexistent. This is growth in the number of health care bureaucrats on the phone today telling you why you can't get the health care coverage you paid for or telling you that you have a preexisting condition and throwing you off health care because you committed the crime last year of getting sick. That growth is through the roof. This is where our health care dollars are going. This is why we need a single-payer system.

According to Dr. Uwe Reinhardt in testimony before Congress, Duke University Hospital, a very fine hospital, has almost 900 billing clerks to deal with hundreds of distinct managed care contracts. Do you know how many beds they have in that hospital? They have 900 beds. They have 900 bureaucrats involved in billing for 900 beds. Tell me that makes sense.

At a time when the middle class is collapsing and when millions of Americans are unable to afford health insurance, the profits of health insurance companies are soaring. From 2003 to 2007, the combined profits of the Nation's major health insurance companies increased by 170 percent. While more and more Americans are losing their jobs, the top executives of the industry are receiving lavish compensation packages. In 2007, despite plans to cut 3 to 4 percent of its workforce, Johnson & Johnson found the cash to pay its CEO Weldon $31.4 million. Ron Williams of Aetna took home over $38 million, and the head of CIGNA, Edward Hanway, took away $120 million over 5 years on, and on and on it goes.

So what is the alternative? Let me briefly describe the main features of a Medicare-for-all single-payer system. In terms of access, people getting into health care, this legislation would provide for all necessary medical care without cost sharing or other barriers to treatment. Every American--not 94 percent but 100 percent of America's citizens--would be entitled to care. In terms of choice, the issue is not choice of insurance companies that our Republican friends talk about. The question is choice of doctors, choice of hospitals, choice of therapeutic treatments. Our single-payer legislation would provide full choice of physicians and other licensed providers and hospitals. Importantly--and I know there is some confusion--a single-payer program is a national health insurance program which utilizes a nonprofit, private delivery system. It is not a government-run health care system. It is a government-run insurance program. In other words, people would still be going to the same doctors, still going to the same hospitals and other medical providers.

The only difference is, instead of thousands of separately administered programs run with outrageous waste, there would be one health insurance program in America for Members of Congress, for the poorest people in our country, for all of us. In that process, we would save hundreds of billions of dollars in bureaucratic waste. In terms of benefits, what would you get? A single-payer program covers all medically necessary care, including primary care, emergency care, hospital services, mental health services, prescriptions, eye care, dental care, rehabilitation services, and nursing home care as well. In terms of medical decisions, those decisions under a single-payer program would be made by the doctors and the patients, not by bureaucrats in insurance companies.

If we move toward a single-payer program, we could save $350 billion a year in administrative simplification, bulk purchasing, improved access with greater use of preventative services, and earlier diagnosis of illness.

People will be able to get to the doctor when they need to rather than waiting until they are sick and ending up in a hospital.

Further, and importantly, like other countries with a national health care program, we would be able to negotiate drug prices with the pharmaceutical industry, and we would end the absurdity of Americans being forced to pay two, three, five times more for certain drugs than people around the rest of the world.

Every other industrialized country on Earth primarily funds health care from broad-based taxes in the same way we fund the Defense Department, Social Security, and other agencies of government, and that is how we would fund a national health care program.

Let me be specific about how we would pay for this. What this legislation would do is, No. 1, eliminate--underline ``eliminate''--all payments to private insurance companies. So people would not be paying premiums to UnitedHealth, WellPoint, Blue Cross Blue Shield, and other private industry companies--not one penny. The reason for that is that private for-profit health insurance companies in this country would no longer exist.

Instead, this legislation would maintain all of the tax revenue that currently flows into public health programs like Medicare, Medicaid, and CHIP, and it would add to that an income tax increase of 2.2 percent and a payroll tax of 8.7 percent. This payroll tax would replace all other employer expenses for employee health care. In other words, employers in this country, from General Motors to a mom-and-pop store in rural America, would no longer be paying one penny toward private insurance revenue.

The income tax would take the place of all current insurance premiums, copays, deductibles, and all other out-of-pocket payments made by individuals. For the vast majority of people, a 2.2-percent income tax is way less than what they now pay for all of those other things. In other words, yes, you would be paying more in taxes. That is true. But you would no longer have to pay for private health insurance, and, at the end of the day, from both a financial perspective and a health security perspective, we would be better off as individuals and as a nation.

What remains in existence--I should add here--is the Veterans' Administration. I believe, and most of us believe, they have a separate set of issues, and the VA would remain as it is.

Let me bring my remarks to a close by giving you an example of where I think we should be going as a country in terms of health care. Oddly enough, the process that I think we should be using is what a small country of 23 million people--the country of Taiwan--did in 1995. In 1995, Taiwan was where we are right now--massive dissatisfaction with a dysfunctional health care system--and they did what we did not do. They said: Let's put together the best commission we can, the smartest people we know. Let's go all over the world. Let's take the best ideas from countries all over the world.

As Dr. Michael Chen, vice president and CFO of Taiwan's National Health Insurance Bureau, explained in an interview earlier this year, the Taiwanese ultimately chose to model their system--after a worldwide search--on

our Medicare Program. That is where they went, except that they chose to insure the entire population rather than just the elderly. After searching the globe, the Taiwanese realized what many Americans already know: a Medicare-for-all, single-payer system is the most effective way to offer quality coverage at a reasonable price.

Taiwan now offers comprehensive health care to all of its people, and it is spending 6 percent of its GDP to do that while we spend 16 percent of our GDP. But, unfortunately, the single-payer model was not ever put on the table here. Maybe we should learn something from our friends in Taiwan.

Let me end by saying this: This country is in the midst of a horrendous health care crisis. We all know that. We can tinker with the system. We can come up with a 2,000-page bill which does this, that, and the other thing. But at the end of the day, if we are going to do what virtually every other country on Earth does--provide comprehensive, universal health care in a cost-effective way, one that does not bankrupt our government or bankrupt individuals--if we are going to do that, we are going to have to take on the private insurance companies and tell them very clearly that they are no longer needed. Thanks for your service. We don't need you anymore.

A Medicare-for-all program is the way to go. I know it is not going to pass today. I know we do not have the votes. I know the insurance company and the drug lobbyists will fight us to the death. But, mark my words, Madam President, the day will come when this country will do the right thing. On that day, we will pass a Medicare-for-all single-payer system.

Madam President, I now move to table Senator Hutchison's motion to commit, and I ask for the yeas and nays.

Mr. President, as an Independent, let me try to give an independent assessment of where we are--which ain't easy, because this is a 2,000-page bill and different people have expressed different thoughts about it. I know my Republican friends are down here on the floor every day telling us that the world as we know it will rapidly come to an end if this legislation is passed, and yet I want to say to them: Where were they for 8 years? Where were they during the 10 years of President Bush? Some 7 million Americans lost their health insurance, health premiums soared, and tens of thousands of people died every single year because they couldn't get to a doctor. Where were they? It is very easy to be critical, but it might have been a good idea if 5 or 6 or 8 years ago they were down here before the crisis erupted to the level it is right now.

This bill, in my view, is far from perfect, and I am going to talk about some of the problems I have with it, but I also want to very briefly outline some of the real assets, positive provisions that are in this legislation. It is not insignificant that this bill provides insurance for 31 million Americans who have no insurance. That is a huge step forward for our country. It is not insignificant that this legislation provides for major health insurance reform, finally outlawing some of the most outrageous behavior patterns of the private insurance companies--practices such as denying people coverage for preexisting conditions, behaviors such as not renewing health insurance because somebody committed the crime the preceding year of getting sick and running up a huge bill. It eliminates caps on the amount of money that people need. Well, you know what, if people need cancer surgery, it is expensive, and you can't tell them there is going to be a cap on what they receive. This bill, importantly, says to families with young people that young people will get coverage until they are 26 years of age. That is a very important provision. All of those are very important steps forward.

Having said that, let me also mention that this bill is strong on disease prevention. The Senator from Iowa, Tom Harkin, has talked for years about the need to understand why we are seeing more and more people coming down with cancer or heart disease or diabetes or other chronic illnesses, which not only cause death and pain and suffering but huge expenditures for our health care system. It seems to me to make a lot more sense to get to the root of the causation of those problems, try to prevent them, and in the process keep people healthy, and save our system substantial sums of money. We have a lot of resources in there for disease prevention.

Those are a few of the positive elements that are in this bill, and I congratulate the people who have fought to make those provisions possible. But let me talk about some of the weaknesses in this bill and some of the areas where I have real concern.

Right now, today, we are spending almost twice as much per person on health care as any other major country on Earth, despite the fact our health care outcomes in many cases are not as good. Can I stand here with a straight face and say we have got strong cost-containment provisions in this legislation; that if you are an ordinary person who has employer-based health care your premiums are not going to go up in the next 8 years based on what is in this bill? I can't say that. It is not accurate. So we need to have in this bill, as we proceed on it, to make sure there are far stronger cost-containment provisions than currently exist.

To my mind, at the very least, we must have a strong public option to provide competition to the private insurance companies that are raising their rates outrageously every single year. What is to prevent them from continuing to do that under this legislation? Not a whole lot, frankly. So the fight must continue for strong public options, not just to give individuals a choice about whether they have a public plan or a private plan but to also provide competition to the private insurance companies.

Second, let me tell you another concern I have. Right now, our primary health care system in this country is on the verge of collapse. There are people all over this country who cannot get in to see a doctor. In fact, we have some 60 million people in medically underserved areas. Most of them can't get to a doctor. What they end up doing is going to an emergency room. They get sicker than they should be and end up going to a hospital, at great expense to our system, and adding a lot of human suffering. What I worry about, if we add 15 more million into Medicaid, if we add another 16 million people into private health insurance, where are those people going to get the primary health care they desperately need? The system is inadequate now. It certainly does not have the infrastructure to address 31 million more people who are getting health insurance.

The good news is that in the House there is language put in there-- and fought for by Congressman Jim Clyburn--that would add $14 billion over a 5-year period in order to see a significant expansion of community health centers and the National Health Service Corps. Community health centers today are providing primary health care, dental care, low-cost prescription drugs, mental health counseling to some 20 million people. What is in the House bill is language that greatly expands that program and also expands the National Health Service Corps, which provides debt forgiveness for medical students who are going to practice primary health care, dental care, or nursing in underserved areas.

We desperately need more primary health care physicians. Certainly we have to change reimbursement rates, but one way we can help is that when medical school students are graduating with $150,000 in debt, debt forgiveness will help them be involved in primary health care. So this is an absolutely essential provision we have got to adopt. We have to do what the House did and provide at least $14 billion more for primary health care, an expansion of community health centers and the National Health Service Corps.

There is another issue. I know there are not many people in this institution who agree with me--although there are millions of Americans who do--that at the end of the day we have to understand that one of the reasons our current health care system is so expensive, so wasteful, so bureaucratic, so inefficient is that it is heavily dominated by private health insurance companies whose only goal in life is to make as much money as they can. We have 1,300 private insurance companies administering thousands and thousands and thousands of separate plans, each one designed to make a profit. The result is we are wasting about $400 billion a year on administrative costs, profiteering, high CEO compensation packages, advertising, and all the other stuff that goes with the goal of private insurance companies to make as much money as they can. So I will be offering on the floor of the Senate, I believe for the first time in history, a national single- payer program, and I look forward to getting a vote on that.

I am not naive; I know we will lose that vote. But I will tell you, at the end of the day--not this year, not next year, but sometime in the future--this country will come to understand that if we are going to provide comprehensive quality care to all of our people, the only way we will do that is through a Medicare-for-all, single-payer system, and I am glad to be able to start that debate by offering that amendment.

But more importantly for the immediate moment, we have language in this legislation which must be improved which gives States--individual States--the right, if they so choose, to go forward with a great deal of flexibility in order to provide quality care to all of their people. Many States may look at a single payer, other States may look at other approaches. But I believe it is absolutely imperative--and I am working with Senator Ron Wyden on this issue--to give maximum flexibility to States to be able to take the money that otherwise would be coming in to their State to use for their own innovative health care programs designed to provide quality, universal, comprehensive health care in a cost-effective way. Some may choose to go single payer, some may choose to go in another direction. We have language in there which must be improved so that States can begin that process when the exchange comes into effect in 2014.

I want to touch on two other issues briefly. The House has very good language in determining how we are going to pay the $800 billion to $900 billion we are spending. What the House says is there should be a 5.4 percent surtax on adjusted gross income above $2.4 million for individuals and $4.8 million for couples. That means nobody in this country who is making less than $2.4 million or less than $4.8 million as a couple will pay one nickel.

What we have here in the Senate, unfortunately, is a tax on health insurance programs which, in fact, will result in the middle class paying, over a period of time, a not so insignificant amount of money as part of this process.

I ask unanimous consent for 5 more minutes.

Mr. President, in joining me, Senators Brown and Franken are supporting this amendment, as well as the AFL-CIO, the National Education Association, the International Brotherhood of Teamsters, the Communication Workers of America, the United Steelworkers of America, the American Postal Workers Union, and many other organizations representing millions of Americans.

The bottom line here is that at a time when we are in the worst economic crisis since the Great Depression, do we want to ask the middle class to pay more in taxes as part of health care reform or should we ask the wealthiest people in this country to start paying their fair share of taxes? I think the evidence is overwhelming that we should do that.

I would point out that, according to the consultant group Mercer, the Senate tax on health insurance plans--despite what we are hearing about a so-called Cadillac plan--would hit one in five health insurance plans in 2013. The CBO has estimated that this tax would affect 19 percent of workers with employer-provided health coverage in 2016. So what we have got to do is junk the tax on health insurance plans, move to the House provision, which says let us ask the wealthiest people in this country to pay a modest amount in order to make sure many more Americans have health insurance.

The last point I want to make is that in the current bill being debated now there is a provision which deals with the reimportation of prescription drugs. This is an issue I have been involved in almost since I have been in the Congress. I was the first Member of the Congress to take Americans into Canada, across the dividing line, in order to purchase low-cost prescription drugs. I will never forget the reality that women who were with me from Franklin County, VT, ended up paying one-tenth the price for Tamoxifen--a widely used breast cancer drug--than they had been paying in the United States. They pay one- tenth the price in Montreal, Canada, for the same exact medicine.

We have to be bold. I know and you know that the drug companies are very powerful. They are delighted that the American people are paying by far the highest prices in the world for prescription drugs. That is good for them. They are making a lot of money. But it is not good for the average American who cannot afford to buy the prescription that his or her doctor is writing. So we have to pass prescription drug reimportation. We have to lower the cost of prescription drugs in this country significantly.

The bottom line here is that this bill has a number of very important features which I think will make life easier for a lot of our fellow Americans. There are problems remaining, and I hope that in the coming weeks we will successfully address those problems.

With that, I yield the floor.

Will the Senator from Minnesota yield?

What I wanted to do is to get back to an issue that is of great importance to the American people, in addition to everything Senator Franken appropriately pointed out; that is, as we proceed forward on this legislation, there is a provision in the Senate bill that I think needs to be changed. I have offered an amendment to do that. I am delighted Senator Brown and Senator Franken and Senator Begich, who is not here, and Senator Burris, who is also not on the Senate floor, are in support of that amendment, as I think the vast majority of the American people are.

Madam President, this bill is going to cost some $800 billion to $900 billion, and the American people want to know where that money is going to come from. Is it going to come from the middle class whose incomes in many ways are shrinking, who have lost their jobs, are having very serious financial problems, or is it going to come in a more progressive way?

The amendment that we are supporting would simply say we will get rid of the 40-percent excise tax on health care benefits above a certain limit and move toward a more progressive way of funding, which is close to what exists in the language in the House.

Essentially, what we would be doing is addressing the fact that the so-called Cadillac plan is not a Cadillac plan because in a relatively few years, millions of workers with ordinary health care benefits are going to be impacted by that. According to a major health care consultant, the Mercer Company, this tax would hit one in five health insurance plans by the year 2016--one in five. The Communications Workers of America have estimated that this would cost families with a Federal employees health benefit--Federal employees with a standard plan with dental and vision benefits--an average of $2,000 per year over the 10-year course of this bill.

So what this issue is about is do we sock it to the middle class again, with the heavy tax that over a period of years is going to impact more and more ordinary families, or do we say that at a time when we have the most unequal distribution of wealth and income, when President Bush gave huge tax breaks to the wealthiest people, that maybe we ask people who have a minimum income of $2 million a year to start picking up their fair share?

I yield to my friend from Ohio.

Interesting that the Senator asks that. What this amendment does is it imposes a 5.4-percent surtax on adjusted gross incomes above $2.4 million for individuals and $4.8 million for couples.

What that means, I would tell the Senator from Ohio, is that this impacts the top two one-hundredths of 1 percent, which means 99.98 percent of the American people would not pay one penny in additional taxes. It is the top two one-hundredths of 1 percent, and I think that is in fact the proper thing to do.

That is true. Of the approximately 134 million individual tax returns filed in 2005, which is the latest data we have available, only two one-hundredths of 1 percent or about 26,000 individuals reported adjusted gross incomes over $2.4 million.

That is right.

Let me pick up on the point the Senator from Minnesota made. When you use the term ``Cadillac,'' the implications are that maybe we will get some of those guys at Goldman Sachs who have this off-the-wall outlandish benefit package.

The reality is, the CWA--Communications Workers of America--has done a bit of work on this. What their

estimate is, as health care costs continue to rise--and we are seeing 6 percent, 7 percent, 8 percent increases every year--obviously, the way the language of this legislation is written, it will impact more and more health care plans. By the year 2019, it will burden one out of three health care plans in this country. Does that sound like a Cadillac plan, one out of three plans? And eventually, as health care costs continue to rise, it will impact virtually every plan in this country.

The bottom line we are talking about is, yes, we need to raise money. How do you do it? Do you do it by socking it to the middle-class and working families? And as the Senator from Ohio has indicated, many of these workers have given up wage increases in order to maintain a strong health care benefit. Are those the people we are going to tax or do you tax the top two one-hundredths of 1 percent, many of whom have received generous tax breaks in recent years?

I think the evidence is overwhelming that one of the reasons we have seen recordbreaking deficits and we have a $12 trillion national debt--it is not just the war in Iraq but also the huge tax breaks that have been given to the very wealthiest people in this country. As the Senator from Ohio indicated, the facts are very clear. Yes, the middle class may have gotten some benefit, but the lion's share of tax breaks went to the people on top.

What we are seeing in this country is a growing gap between the very wealthy and virtually everybody else. In many ways, the middle class is shrinking. Poverty is increasing. It makes zero sense to me that in the midst of all of that, we ask the middle class to pay more in taxes to provide health care to more Americans and we leave the top one- hundredth of 1 percent alone.

Let me also say this: There is a lot of support out there for the amendment Senator Brown, Senator Franken, Senator Begich, Senator Burris, and I are offering. Let me just read one. This is from the president of the Fraternal Order of Police. These are cops out on the street. Most people do not think the police are getting extravagant health care benefits.

This is what he said:

I am writing to you on behalf of the membership of the

Fraternal Order of Police to express our support for your

amendment which would eliminate the excise tax on high cost

insurance plans.

Et cetera, et cetera.

This provision is intended to tax the health plans of the

wealthiest Americans, but it will also tax the plans of many

law enforcement officers who need high cost and high quality

insurance due to the dangerous nature of their profession.

The Fraternal Order of Police strongly supports your

amendment, because health care reform legislation should not

increase the tax burden for those who fearlessly risk their

health, and even their lives, to keep our communities safe.

If I could jump in, a moment ago Senator Brown asked me a question about the extent of the tax breaks given to the wealthiest people, and I do have that information. Since 2001, I say to Senator Brown, the richest 1 percent of Americans received $565 billion in tax breaks. In 2010 alone, the most wealthy 1 percent of Americans are scheduled to receive an additional $108 billion in tax breaks. That is point No. 1.

Point No. 2--let me be a little political here. In the Presidential election of 2008, one of the candidates said that it was a good idea to tax health care benefits. That candidate--Senator McCain--lost the election. The other candidate said it was a bad idea to tax health care benefits. That was Barack Obama; he won the election.

Let me quote from what then-Senator Obama said when he was running for President. On September 12, 2008, he said:

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

less than $250,000 will see their taxes increase, not your

income taxes, not your payroll taxes, not your capital

gains taxes, not any taxes. My opponent, Senator McCain,

cannot make that pledge and here is why. For the first

time in American history--

This is Senator Obama speaking about Senator McCain's plan.

For the first time in American history, he, Senator McCain,

wants to tax your health benefits. Apparently, Senator McCain

doesn't think it's enough that your health premiums have

doubled. He thinks you should have to pay taxes on them, too.

That's his idea of change.

I agree with what Senator Obama said in 2008. I disagree with what Senator McCain said then. Right now, we are in a position to follow through on what Senator Obama said at that point and make sure the middle class of this country does not pay taxes on their health benefits.

If I could just add to the point Senator Brown and Senator Franken have made regarding concern about the national debt, every day there is a Republican coming up here to say we have a $12 trillion national debt and we have to cut this and cut that--all that. Yet I think virtually every one of them is in support of the repeal of the asset tax, which would benefit solely the top three-tenths of 1 percent and would cost the Treasury $1 trillion over a 20-year period-- $1 trillion over a 10-year period. I am sorry, $1 trillion over a 10- year period.

I am really concerned about the deficit, I am concerned about the national debt, but I am prepared to vote for repealing the entire estate tax which only impacts--gives $1 trillion in tax breaks over a 10-year period to the top three-tenths of 1 percent.

Some may question the sincerity about their concern about the national debt.

I am talking about what happens now. Overall, the vast majority of our Republican friends----

Want to abolish the estate tax, which is $1 trillion in tax breaks.

The Senator is so nice.

Madam President, polls show there is overwhelming support among the American people for what we are discussing today. Organizationally, it has the support of the AFL-CIO, the National Education Association, the Fraternal Order of Police, the United Steelworkers of America, AFSCME, the American Postal Workers Union, and a number of other organizations representing millions of working people. This is not a complicated issue. Somebody will have to pay for this bill. Should it be the middle class and working families or should it be the people at the top two one-hundredths of 1 percent who, over the period of the last 8 or 9 years, have enjoyed huge tax breaks? This is kind of a no-brainer.

The good news here is that our friends in the House have moved correctly in this area. The bill before us in the Senate does not. What we are trying to do is to get an amendment to take out the tax on health care benefits and replace it with similar language, not exactly the same as exists in the House.

Right.

That is the point. The point is that medical costs are going up substantially more than inflation. In fact, general inflation is actually going down. There is no question but that as medical inflation continues to remain high, millions and millions more workers are going to be forced to pay this tax. One of the other side effects of this tax is that many employers, in order to avoid it, are going to start cutting the health care benefits that workers receive. Today it may be dental; tomorrow it will be vision. The next day it will be more copayments, more deductibles. This is grossly unfair to working families.

Madam President, how much time do we have remaining?

I think we are coming to the end of it. I hope, focusing on the issue of the excise tax, the Senate is prepared to support our amendment. If that is not the case, certainly support what the House has done in the conference committee. Taxing middle-class workers is not the way we should fund health care reform.

Mr. President, when Republicans controlled the White House, the Senate, and the House, they had the opportunity to do something about the health care disaster in America. From 2000 to 2008, some 7 million Americans lost their health insurance. Where were the Republicans? During that same period, health care costs soared in America. Small businesspeople found themselves unable to provide health care to their workers.

Where were our Republican friends? I am delighted they are down on the floor every single day criticizing an effort to try to improve the situation. But it might have been a little better if they were here 8 years ago, bringing forth their ideas. But they were not.

Having said that, let me suggest that in the midst of this health care crisis, in which 46 million Americans have no health insurance and health care costs are soaring and, as the President indicates, that will double in 8 years if we do nothing, at a time when 45,000 Americans this year will die because they don't get to a doctor when they should, when close to 1 million Americans are going to go bankrupt from medically related bills, we need real health care reform.

That is something that I, and I know many other Members in Congress, have been fighting for for years. More than anything, I wish to see us pass strong health care reform. I must express a disagreement with some of my colleagues on the Democratic side, who think we are on the 2-yard line, we are almost there. I don't think so. I think there are a number of problems that remain in this legislation that have to be resolved. I wish to touch on a few of them.

One of the parts of this legislation is that, finally, we are going to add some 30 million Americans to health care insurance. That is a good thing. About half of them will be added to an expanded Medicaid--a huge expansion of Medicaid. But here is my concern. Right now, our primary health care system is extremely weak. Everybody knows we don't have enough primary health care doctors. We know that Medicaid, today, is on wobbly legs as it tries to take care of the people who access that program. I am not quite sure how you add 15 million more people to Medicaid if you don't have a primary health care infrastructure to accommodate their needs.

In this regard, I have fought very hard for authorization language in the Senate to greatly expand community health centers and the National Health Service Corps, for which we will train and make sure that we have the primary health care doctors, dentists, and nurses we need, desperately need.

In the House bill, there is language introduced by Representative Clyburn, supported by the Democratic leadership, that would provide $14 billion over a 5-year period to expand community health centers, enable tens of millions more to access health care, and make sure we have the primary health care doctors and dentists we need.

It would be a cruel hoax to tell people they now have health insurance--Medicaid or another program--but not create a situation by which they can get into the doctor's office. I fear that may happen. I am going to fight as hard as I can to make sure we have the primary health care infrastructure we need. That means, in the Senate, adopting the language that currently exists in the House bill for $14 billion over a 5-year period--money which, according to a variety of studies, will pay for itself as we keep people out of the emergency room and keep people from getting sicker than they otherwise should be and ending up in a hospital. This makes a lot of sense. Community health centers have had wide bipartisan support. We have to support the House language.

On another issue, I found it interesting that my friend from Kansas, a moment ago, was denouncing the United Kingdom's health care system, denouncing socialized medicine, single payer. Well, I got a little confused by my Republican friends, who have been in Congress, saying: We love Medicare. My word, do we love Medicare. We are very angry that those Democrats are trying to cut back on that.

Republicans who, year after year, wanted to privatize Medicare, this week they love it. If they love it so much, why don't they join us in trying to expand Medicare and address some of the problems in Medicare? Let's work together.

Last week, we were criticized, but now, I guess, the tune has changed a little. Get your act together, my Republican friends. Either you continue the line you have had for many years about detesting Medicare because it is a single-payer health care program, a government health care program--that is what it is, a single-payer government health care program. You have been on the floor defending it all week long, until a couple days ago.

I support Medicare. In fact, what I believe and am fighting for is a Medicare-for-all, single-payer program because, at the end of the day, I disagree with many on this side of the aisle. I think, at the end of the day, the only way you are going to provide comprehensive universal health care to all Americans, in a cost-effective manner, is through a Medicare-for-all, single-payer system, which ends the hundreds of billions of dollars of bureaucracy and waste engendered by the private insurance companies.

One of my concerns, as we seem to be hurtling down the finish line, is I don't know who is going to be able to offer amendments. I have an amendment that speaks to what millions of Americans want, including the Physicians for a National Health Program--17,000 doctors, mostly primary health care doctors but not exclusively. They want to see this country have a Medicare-for-all, single-payer system. I understand I am not going to get very many Republicans supporting that amendment--or any Republicans. I also understand I will get few enough Democrats supporting that amendment. In the years to come, we are going to have a Medicare-for-all, single-payer system. I want that debate on the floor of the Senate. I have offered an amendment and I want to have that debated. I don't need 20 hours or 5 days. I would love to discuss that issue with my Republican friends.

Democrats, I think it is an amendment that has a right to be offered and it should be. I understand that will not pass. I will tell you what could pass and what could have Republican support, it is the provision I have been working on that at least says that in our Federalist system, where each State learns from other States, at least give States the option. If the Governor or the legislature wants to go forward with a single-payer model; maybe it works, maybe it doesn't work. I have the feeling if one State--whether it is Vermont, California, Pennsylvania, States that have strong single-payer movements, a lot of support for that concept--if one State does it well, then other States will be saying we want the same thing. It is a cost-effective way to provide comprehensive health care to all our people.

I want to touch on another issue, where I think my colleagues in the Senate are wrong and my former colleagues in the House are right. This is an issue the occupant of the chair has worked on with me. We held a press conference this morning. It is to understand this legislation is going to cost between $800 billion and $1 trillion.

How do you get the money? Well, the Senate bill contains a tax on health insurance benefits. I think that is wrong. I think that is regressive. It is called a tax on Cadillac plans. Given the soaring cost of health care in America today, what may be a Cadillac plan today will be a junk car plan 5 years from now. Millions of Americans are going to be forced to pay taxes on their health care benefits or else their employer will cut back on those benefits, and they are going to have to pay out of their own pockets. That is wrong. It is a regressive and unfortunate and unfair way to raise the revenue we need.

Our friends in the House did the right thing. They said that millionaires should be asked to pay a little bit more in taxes to make sure we expand health care coverage in this country. I support what our friends in the Senate and the House did, and I disagree with what is in the Senate bill. There will be a poll coming out this afternoon in which 70 percent of the American people, as I understand it, disagree with the tax on

health care benefits. They understand that is a tax on the middle class.

Let's be clear. We are in a terrible recession now. Working families are struggling. It is wrong for us to propose a tax on health care benefits, which in a few years will be impacting millions of middle- class workers. We should follow what the House has done and say to people at the top--millionaires who have received huge tax breaks under President Bush--that they have to pay a little bit more in taxes so we can provide health care to all our people.

There is a lot in the bill in the Senate that makes a lot of sense to me. I congratulate Senator Dodd and Senator Baucus and all those people and their staffs who have worked so very hard on this bill. We have 31 million more people who will get insurance. There is insurance reform dealing with preexisting conditions. We made progress in disease prevention. There are a lot of good things in it.

I want to be very clear: I do not think we are at the 2-yard line. I think a lot of work has to be done to improve this bill. We need to, as I mentioned a moment ago, make major improvements in primary health care. We need to change how we fund many parts of the expansion of insurance and do away with the tax on health care benefits. We have to give States the option, the flexibility to go forward with a single- payer system if that is what they want to do.

Also, I hope very much that this afternoon we will vote and adopt the reimportation prescription drug legislation championed by Senator Dorgan. It is an absurdity in this country that we remain the country that pays by far the highest prices in the world for prescription drugs. When I was in the House, I was the first Member of Congress, as I understand it, to take Americans over the Canadian border. Back then--10, 15 years ago--women were able to purchase the breast cancer drug Tamoxifen for one-tenth the price they were forced to pay in the United States. I know the drug companies are very powerful. I know they have a lot of influence in this institution. But I hope we can do the right thing and provide affordable medicine to all Americans through reimportation. And I hope we can adopt that amendment.

I did want to say I have some very serious concerns about this legislation, and I hope they will be addressed in the coming days and weeks. I very much want to be able to vote for this bill, but I am not there now, not by any means.

I yield the floor.

Mr. President, I thank the chairman for yielding. Before I get into the subject I wish to talk about, which is prescription drug reimportation and the absolute necessity of lowering the cost of prescription drugs in this country, I wish to say a word in general.

I find it interesting that my Republican friends are spending a whole lot of time down here on the floor attacking the health care legislation. I suppose it is at least a positive thing that they are beginning to talk about health care. They ran the government from 2000 to 2006. They had the President, they had the House and the Senate. At that time, health care premiums soared. Millions of Americans lost their health insurance. Where were they? Where were they in the beginning to come up with ideas to control health care costs and provide health care to more Americans? They weren't there.

Now, having said that, let me also say I have problems with the bill that is currently on the Senate floor. Clearly, it does a lot of things that are good, but there are weaknesses in this bill in terms of cost containment that we have to address.

When some of my friends talk about expanding Medicaid and the problems associated with that, they make a good point. We need to significantly expand our primary health care capabilities, which means more community health centers, which means more primary health care physicians. If we are not able to do that while we add 15 million more people to Medicaid, frankly, I am not sure how we are going to deal with the medical needs of those people.

So I think one of the imperatives that has to happen as we proceed on this bill is we have to support the language in the House, which substantially increases funding for community health centers and for the National Health Service Corps, so that we give a primary health care infrastructure--clinics and doctors--to begin to serve the millions more Americans who are going to be coming into the health care system.

That is one issue. The other issue I wanted to focus on today--and I am here because Senator Dorgan, who is the sponsor of this legislation, is unable to be on the floor of the Senate at this time--deals with prescription drug reimportation. This is an issue I have worked on for many years. When I was Vermont's Representative in the U.S. House, I believe I was the first Member of Congress to take American citizens over the Canadian border--in this case to Montreal--in order to purchase affordable prescription drugs.

I will never forget--never forget--the bus trip we took over from St. Albans, VT, to Montreal, Canada. On that bus there were a number of lower income

women who were struggling with breast cancer. Many of them were using the widely used breast cancer drug called Tamoxifen. We got off the bus in Montreal, and we walked into the drugstore--and that had all been prearranged--and in there they purchased Tamoxifen. At that point in time--and I am thinking it was about 10 years ago, a while back--they paid, in American dollars, one-tenth of the price for Tamoxifen in Montreal, Canada, that they were paying in the United States of America--one-tenth of the price for lower income women who were struggling for their lives.

So when you talk about morality, I want some of my friends to explain why it is that the American people are forced to pay by far the highest prices in the world for prescription drugs? Talk to physicians in Vermont. There is a doctor I know in northern Vermont, and when she writes a prescription, one-third of her patients cannot afford to fill the prescription. So what is the sense of an examination, a diagnosis, and writing a script when your patient can't even fill that script?

The high cost of prescription drugs in this country is one of the major health care crises we face. It is an issue we have to deal with, and we simply have to ask ourselves why it is that the same exact medicine in this country costs substantially more than it does in Canada, in Australia, or all over Europe.

There has been a lot of concern in this country about the lack of bipartisanship. Well, I have to say that on this issue there is bipartisanship. That was true when I was in the House, and that is true in the Senate.

Let me just read to you the cosponsors of this legislation-- Democrats, Republicans, Independents. The bill is introduced by Senator Dorgan, and the cosponsors are Senator Begich, Senator Boxer, Senator Casey, Senator Conrad, Senator Feingold, Senator Inouye, Senator Klobuchar, Senator Leahy, Senator Lincoln, Senator McCaskill, Senator Sanders, Senator Snowe, Senator Stabenow, Senator Thune, Senator Bingaman, Senator Brown, Senator Collins, Senator Durbin, Senator Grassley, Senator Johnson, Senator Kerry, Senator Kohl, Senator Levin, Senator McCain, Senator Nelson, Senator Shaheen, Senator Specter, Senator Tester.

So there is widespread bipartisan support for legislation which says: Let's end the absurdity of the American people having to pay substantially more for the same exact medicine that is sold in other countries around the world.

Let's take a look at some of these charts. To begin with, we all understand when you deal with the drug companies and the pharmaceutical industry you are dealing with some of the most powerful lobbyists and forces right here in Washington, DC. These people spend huge amounts of money on campaign contributions, huge amounts of money in lobbying. Just recently, in order to make sure they got in under the wire, in case there was some real reform passed in Washington, they substantially raised their prices for particular drugs just in the year 2009, and here is the chart reflecting that: Enbrel, a 12-percent increase; Singulair, 12 percent; Plavix, 8 percent, Nexium, 7 percent; Lipitor, 5 percent; Boniva, 18 percent.

One of the reasons health care costs are soaring in America--and one of the reasons many seniors are having such a difficult time with health care costs--is precisely the rapid rise of prescription drugs.

What I want to talk about now, through this chart, is something that is inexplicable to the average American. This is Lipitor, which is a widely used drug, and here is the cost of Lipitor. The same amount in Canada costs $33; in France, $53; Germany, $48; the Netherlands, $63; in Spain, $32; the United Kingdom, $40; and in the USA, $125, or four times as much as it costs in Canada.

Now, you explain that to me. The same exact medicine made in the same exact factory, the same exact bottle. That is why, by the way, in the State of Vermont, and all across the northern tier, every day people are going over the Canadian border or using the Internet to buy those drugs. So what we are saying in this legislation is let's end this absurdity.

We are living in a global economy. I have a lot of problems with the global economy in many ways, but if, when we go Christmas shopping, the only products we can find are made in China--because we don't do too much manufacturing in America--and if when we eat lunch we get lettuce and tomatoes from all over the world, what people are asking is, why is it we can't bring into this country FDA-safety-approved medicine? We can bring lettuce in from the backwoods of Mexico, and that is OK. But somehow, when we have a handful of major pharmaceutical companies, presumably it is just too difficult to be able to bring them safely into the United States. Nobody believes that for one moment.

Let's take a look at another chart. Plavix, same story: Canada, $85; France, $77; Germany, $85; the Netherlands, $77; Spain, $58; the U.K. $59; and in the USA, $133. Somebody explain this to me. I really would appreciate it.

Nexium: Canada, $65; Germany, $37; Spain, $36; the UK, $41; and the United States of America, $424. That is six times more than in the United Kingdom. People wonder why Americans are running over the Canadian border or they are on the Internet trying to get this medicine.

Why is it that the drug companies charge $424 here and $41 in the UK? Well, the reason they are charging more here is because they can charge more. If you walk into your drugstore tomorrow, you can find the prices that you will pay are double, triple because we are the only country in the world that does not have, in one way or another, some kind of regulation on prices. All these other countries have national health care programs. That is another reason their drug prices are lower. We don't, of course.

But at the very least, what reimportation is all about is, we are saying, in a global economy, when all kinds of products are brought in from all over the world and we let the consumer buy them every day, why not let the pharmacist, let the prescription drug distributor be able to take advantage of the global economy?

I am not, I must confess, a great supporter of unfettered free trade. I think that has, in many ways, been a disaster for American workers. But to the degree that it is here, to the degree businesspeople can run to China and pay workers there 50 cents an hour or so, that is the global economy. Well, here is the global economy: Canada, $65; the UK, $41; and the USA, $424. Why can't prescription drug distributors purchase their products in the UK, bring them back into America, so we can substantially lower the cost of health care and prescription drugs for all Americans?

Some of my friends in the pharmaceutical industry say: It is impossible to bring medicine in from abroad. It can't be done safely. Well, the Washington Post says:

40 percent of active ingredients in U.S. prescription drugs

currently come from India and China.

I guess that is OK for the pharmaceutical industry, when it adds to their profits, but we can't do that to lower the cost to the consumer.

The Wall Street Journal, February 21, 2008, says:

More than half the world's Heparin, the main ingredient in

the widely used anti-clotting medicine, gets its start in

China's poorly regulated supply chain.

Well, I guess that is OK too.

So here is where we are. One of the many health care crises we face in this country is the high cost of prescription drugs. I think there is a lot that we have to do. Whether the Congress is capable of standing up to the drug companies and all their money and all of their lobbyists remains to be seen. But this is, quite frankly, a no-brainer.

For all my colleagues here who believe in unfettered free trade, please do not be total hypocrites. If you believe in unfettered free trade--which I happen not to--if you believe it is OK for American companies to shut down and run to China, if you think it is OK for people to buy any product anywhere in the world, tell me why we can do that for everything except for prescription drugs? There is no rational explanation.

This is legislation which has been around for years. The drug companies have fought it successfully for years. We now have widespread tripartisan

support in the Senate and a lot of support, I know, in the House. Let's finally stand up for the average American. Let's substantially lower the cost of prescription drugs. Let's pass prescription drug reimportation.

With that, Mr. President, I yield the floor, and I suggest the absence of a quorum.

Mr. President, let me begin by thanking Senator Casey for his consistent efforts in fighting to make sure that every American has good-quality, cost-effective health care. He has been a leader and I congratulate him.

Mr. President, I wish to touch on some of the health care issues that are out there and tell you what I think is positive in the bill we are dealing with in the Senate and tell you what I think is not so positive.

To begin with, as Senator Casey has aptly described, we have a system which, in many ways, is disintegrating. It is an international embarrassment that in the United States of America, we remain the only Nation in the industrialized world that does not guarantee health care to all its people as a right. The result of that is, some 46 million Americans today have no health insurance. Even more are underinsured, with large copayments and deductibles.

We have some 60 million Americans today who, because of our very poor primary health care outreach network, do not have access to a doctor on a regular basis. The result of that is, as incredible as it may sound, according to a recent study at Harvard University, some 45,000 people die every single year because they do not get to a doctor when they should. As a result, by the time they walk into a doctor's office, their illness may be terminal. In addition to that, God only knows how many people end up in a hospital, at great expense to the system, because they did not get care when they should have.

Meanwhile, as Senator Casey indicated, bankruptcy is an enormous problem because of our health care system. Close to 1 million Americans this year will be going bankrupt because of medically related bills. Furthermore, when we talk about economic growth in America, all of us understand that small businesses, medium-sized businesses are plowing an enormous amount of money into health care for their workers rather than reinvesting that money and expanding their operations and creating the kind of jobs we need as a nation in the midst of our very deep recession.

We have a major problem. At the end of the day, despite so many people uninsured, underinsured, so many people dying because they do not get health care when they need it, so many people going bankrupt, we end up spending almost twice as much per capita on health care as any other nation.

It is clear to me and I think it is clear to the vast majority of the American people that we need real health care reform. What real health care reform must be about is at least two things. No. 1, providing coverage to all Americans as a right of citizenship and, No. 2, doing that in the most cost-effective way we possibly can.

To my mind, quite frankly, there is only one way that I know of that we can provide universal, cost-effective, and comprehensive health care for all our people, and that is a Medicare-for-all, single-payer system. Very briefly, the reason for that is we are wasting about $400 billion every single year on administrative costs, on profiteering, on advertising, on billing--all in the name of profits for the private insurance companies that have thousands and thousands of separate plans out there, creating an enormously complicated and burdensome system. With each one of their thousands of plans, if you are young and do not get sick and are healthy, they have a plan for you. If you are older and you get sick, they have another plan for you. There are 1,300 private insurance companies with thousands and thousands of plans, and to administer all of this costs hundreds and hundreds of billions of dollars.

That is money not going into doctors--we have a huge crisis in primary health care physicians--not money going into dentists. Many areas, including Vermont, have a serious dental access problem. That is money not going to nurses. We have a nursing shortage. This is money going into bureaucracy, profiteering, and salaries for the CEOs of insurance companies. It is going into inflated prices for prescription drugs in this country. As a nation, we pay the highest prices in the world for prescription drugs.

To my mind, as a nation, what we have to finally deal with is that so long as we have thousands of separate plans, each designed to make as much money as possible, we are not going to get a handle on the cost of health care in America.

In the bill we are now talking about in the Senate, we have to be clear that the projections, according to the CBO, are that, everything being equal, over a 10-year period, the cost of health care for most Americans is going to continue to soar. That is the reality. This is bad not only for individuals, not only for businesses, this is bad for our international competitive capabilities because we are starting off from the position that today we spend much more than any other country. Guess what? While this bill does a number of very good things, it is not strong on cost containment.

If we are going to try to improve cost containment--and I wonder how much we can do within the context of this particular approach to health care without being a Medicare-for-all, single-payer system--at the very least, we need a strong public option. We need that for two reasons. First of all, there is widespread mistrust of private health insurance companies for all the right reasons.

Most Americans understand that the function of a private health insurance company is not to provide health care; the function is to make as much money as possible. People do not trust private health insurance companies, and they are right in terms of their perceptions.

People are entitled to a choice. If you want to stay with your private health insurance company, great, you can do it. But as many people as possible in this country should be able to say: You know what, I am not comfortable with a private insurance company. I would rather have a Medicare-type plan.

Poll after poll suggests that the American people want that public option. That is point No. 1, freedom of choice. People should have that choice. If they do not want it, that is fine.

Point No. 2 may be even more important, if we are going to get a handle on exploding health care costs, somebody is going to have to rein in the private insurance companies whose only function in life is to make as much money as they possibly can. We need a nonprofit, government-run public plan to do that. If we do not have that in this bill, I am not sure how we are going to get any handle on cost containment.

I will fight to make sure we have as strong a public option as we possibly can. As I have said publicly many times, my vote for this legislation is not at all certain. I have a lot of problems with this bill. We have to have at least, among other things, a strong public option.

Let me tell my colleagues something else I think we have to address in this bill. As I mentioned a moment ago, we have a disaster in terms of primary health care in America. Some 60 million Americans are finding it difficult to get to a doctor on a regular basis, and that is dumb in terms of the health and well-being of our people. It is also dumb in terms of trying to control health care costs.

If somebody does not have a doctor they can go to when they get sick, where do they end up? They end up in the emergency room, and everybody knows the emergency room, by far, is the most expensive form of primary health care. Yet millions of people have no other options. They end up in an emergency room. If they have a bad cold, Medicaid may pay $500 to $600 for their visit to the emergency room. That is totally absurd.

Furthermore, if you have a primary health care physician, that person can work with you on disease prevention--helping you get off cigarette smoking or helping you with alcohol, a drug problem, a whole myriad of issues in terms of good prevention, good nutrition. That we have a disaster in primary health care which is driving people to the ER makes no sense at all.

As I mentioned the other day, there is a provision in this legislation in the Senate which authorizes a very significant expansion of federally qualified community health centers which, in a nonpartisan way, a bipartisan way is widely supported by, I suspect, almost everybody in the Senate and in the House as well.

These community health centers today allow 20 million people to access not only good, quality primary health care but dental care, which is a huge

issue all over this country, mental health counseling, a very big issue, and low-cost prescription drugs.

The problem is, while the community health centers today do an excellent job, there are not enough of them. So in this legislation, we have greatly expanded community health centers. If we as a Congress are talking about bringing 13, 14, 15 million more people into Medicaid, I am not quite sure how a struggling Medicaid Program is going to accommodate those people, unless we provide the facilities and the medical personnel to treat them.

We need this. We need to expand primary health care. Community health centers are the most cost-effective way I know how to do that. There are studies that suggest providing that primary care, keeping people out of the emergency room, keeping them out of the hospital because they have gotten sicker than they should have gotten, we can, in fact, pay for these community health centers over a period of years by simply saving money.

In the Senate, we have very good language authorizing an expansion. In the House, they have similar language, except in the House they have a trust fund which actually pays for this. I am going to do my best to make sure we adopt the House language, which pays for, through a trust fund, a substantial increase in community health centers and, in addition, a very significant expansion of the National Health Service Corps, which is a Federal program which provides debt forgiveness and scholarships for medical students who are prepared to serve in medically underserved areas in primary health care.

We desperately need more primary health care physicians, nurses, dentists. That is what the National Health Service Corps does. My hope is the Senate will adopt the House provision to greatly expand the National Health Service Corps and the Health Service programs. That is an issue that is very important to me.

Let me touch on another issue, which is clearly going to be contentious; that is, at the end of the day, we are going to be spending on health care somewhere around $800 billion to $1 trillion. The American people want to know a couple of things. They want to know: Is this going to raise our national deficit? What CBO tells us is, no, it will not. More money is going to come in than goes out. There will be savings incorporated in the legislation, and that is a good thing. We have a $12 trillion national debt, and we do not want to add to that.

But people are also asking how are you going to raise the money? How are you going to pay for this? Where does the $800 billion to $1 trillion come from? Here is where we have a bit of differences of opinion.

In the House, I think they have, once again, done the right thing. What the House has done is raise $460 billion, with a surcharge on the top three-tenths of 1 percent of taxpayers. These are the wealthiest people in this country. What the House has said, quite appropriately, is that at a time when the gap between the rich and everybody else is growing wider and at a time when the top 1 percent earn more income than the bottom 50 percent, it is appropriate, especially after all of President Bush's tax breaks, to ask the wealthy to start paying their fair share of taxes so we can provide health insurance to tens of millions of Americans. That, in my view, is exactly the right way to go.

Unfortunately, in the Senate, we have not done that. What we have chosen to do in the Senate is to raise about--I do not know the exact number--but we have chosen to impose an excise tax of 40 percent on so- called Cadillac plans. The problem is, given the substantial increase in health care costs in this country, a Cadillac plan today in 5 or 10 years may be a junk car plan.

I believe with a struggling middle class, with people desperately trying to hold onto their standard of living, the last thing the Senate wants to do is impose a tax on millions and millions of working people who have fought hard to get a halfway decent health care plan.

Let me very briefly read from a fact sheet that came from the Communications Workers of America. CWA is one of the largest unions in this country. Similar to almost every union, they are strongly opposed to this excise tax on health care benefits. This is what they say. I read right from it. This is a document from the CWA:

The U.S. Senate will soon vote on legislation that would

tax CWA-negotiated employer health plans. The tax will be

passed directly onto working families. To avoid the tax,

employers will try to significantly cut benefits for active

workers and pre-Medicare retirees.

How the House Benefits Tax Works.

A 40-percent excise tax would be assessed on the value of

health care plans exceeding $23,000 for a family and $8,500

for an individual starting in 2013. (Levels are higher for

pre-Medicare retiree plans and high-risk industry plans--

$26,000 and $9,850.)

And here is an important point. Because while people may not have to pay this tax in a couple of years, with health care costs soaring, they will have to pay this tax in the reasonably near future.

Quoting from the CWA document:

These ``thresholds'' would increase at the rate of general

inflation, plus 1 percentage point, or 3 percent. This is

well below the medical inflation rate (4 percent) and about

half the rate (6 percent) at which employer and union plan

costs have been increasing.

In other words, the cost of health care is rising a lot faster than inflation, which today is almost zero. It may actually be below zero, the point being that in a number of years, so-called Cadillac plans are going to reach the threshold upon which middle-class workers are going to be forced to pay a lot in taxes.

Let me go back to the CWA now. They write:

Health Benefits Tax Will Hit CWA--

And they are talking about many union workers here.

--CWA-negotiated Plans Hard and Result in Deep Cuts. In 40 of

43 states examined over 10 years (2013-2022) the average

excise taxes assessed on each worker in CWA's most popular

plans will be: $13,300 per active worker in the family plan.

That is for a 10-year period, $13,300.

$5,800 per active single worker, $13,600 for pre-Medicare

retiree in the family plan, and $4,400 for pre-Medicare

retiree in the single plan.

The bottom line is that the middle class in this country is struggling. We are in the midst of the most severe recession since the Great Depression of the 1930s. People are working longer hours for lower wages. The middle class is on the verge of collapse. The Senate should not be imposing an additional tax on middle-class workers. The House got it right; the Senate got it wrong, and I intend to offer an amendment to take out this tax and replace it with a progressive tax similar to what exists in the House.

Let me conclude by simply saying this: I understand that the leadership wants to move this bill forward as quickly as possible. I understand that. But in my view, we have a lot of work in front of us to improve this plan. Among many other things--many other things--and I know other Members have different ideas--at the very least, States in this country--individual States--if they so choose, should be able to develop a single-payer plan for their States. Because at the end of the day, in my view, the only way we are going to provide comprehensive, cost-effective, universal care is through a single payer.

I know some people are saying: Well, we are dealing with health care, we are not going to be back for a long time. If this bill were passed tomorrow, trust me, we would be back in a few years, because health care costs are going to continue to soar. Winston Churchill once said: ``The American people always do the right thing when they have no other option.'' And I think that is what we are looking at right now. We are running out of options.

What we have put together is an enormously complicated patchwork piece of legislation. It is going to help a lot of people. It involves insurance reform, which is absolutely right. We have a lot of money into disease prevention, which we should have. There are a lot of very good things in this bill. But it is not going to solve, in my view, the health care crisis. Costs are going to soar. If we don't have the courage as a body to take on the insurance companies, to take on the drug companies, at the very least let us give States--whether it is Vermont, Pennsylvania, California, or other States--the right to become a model for America; to provide health care to all people in a cost- effective way through a Medicare-for-all, single-payer system. We have to do that.

The other thing we have to do, in my view, is to get rid of this tax on the middle class by taxing health care benefits. Mr. President, you will recall that a year ago we were in a highly controversial and difficult Presidential campaign. One candidate, who happened to have lost that election--a Member of the Senate, Senator McCain--came up with a plan that was exactly--or very close to it--to what we are talking about today. Then-Senator Barack Obama, who won that election, came up with a different plan, because he said that wasn't a good idea. Well, how do you think millions of American workers are going to feel when they say: Wait a second, the guy who won told me he was against taxing health care plans, and now we are adopting the program of the guy who lost. How do the American people who voted in that election have faith in their elected officials if we do exactly what we said we would not do?

So I believe we have to move toward a progressive way of funding this health care plan. As I stand here right now, this plan has a lot of good stuff in it, but there are a lot of problems in it. I very much look forward to the opportunity to be able to offer a number of amendments to strengthen this bill. It is very important to the people of Vermont and to people all over this country that not only I but the Presiding Officer and other Members have a right to offer amendments. Because if this bill gets whizzed right through, and is not as strong as it possibly can be, I think we will not have done the job we need to do.

Mr. President, with that, I yield the floor.

Mr. President, it appears I am going to be closing tonight.

Mr. President, I ask unanimous consent that the Senate proceed to a period of morning business, with Senators permitted to speak for up to 10 minutes each.

Mr. President, I ask unanimous consent that when the Senate completes its business today, it adjourn until 9:30 a.m., Wednesday, December 9; that following the prayer and pledge, the Journal of proceedings be approved to date, the morning hour be deemed expired, the time for the two leaders be reserved for their use later in the day, and the Senate resume consideration of H.R. 3590, the health care reform legislation; that following any remarks of the chair and ranking member of the Finance Committee, or their designees, for up to 10 minutes each, the next 2 hours be for debate only, with the time equally divided and controlled between the two leaders or their designees, with Senators permitted to speak for up to 10 minutes each; the Republicans controlling the first 30 minutes and the majority controlling the second 30 minutes, with the remaining time equally divided and used in an alternating fashion; further, that no amendments are in order during this time.

Mr. President, rollcall votes are possible throughout the day tomorrow. Senators will be notified when any votes are scheduled.

Mr. President, if there is no further business to come before the Senate, I ask unanimous consent that the Senate stand adjourned under the previous order.

Mr. President, there are at least two major goals we have to achieve in health care reform and that is we have to expand access to everyone in America, and we have to control costs. We focus a lot on expanding insurance but expanding insurance is not expanding access. There are people today in America who have insurance but they do not have access. The fact is, we have 60 million people who do not have access to a physician on a regular basis and many of those people--according to recent studies, 45,000--may die because they do not get to a doctor in a timely manner. By the time they walk into the doctor's office their situation is terminal.

We need substantially improved access to health care. When we improve access, we save money because people do not go to the emergency room, they do not end up in the hospital, sicker than they otherwise would have been. We need a revolution in primary health care in America. Unless we do something and do it now, our primary health care system infrastructure is close to collapse.

We have an aging primary care workforce which is not being replaced. At a Senate hearing I chaired earlier this year, it was noted that only 2 percent of internal medicine residents were choosing primary care as their specialty. Happily, there are two Federal programs that can both assure access and control costs, and I refer to the Community Health Center Program and the National Health Service Corps. Both are well- established programs that have garnered broad bipartisan support because of their proven cost effectiveness.

What a federally qualified community health center is about--and I believe they exist in all States in this country. They have widespread support from Members of the Senate and the House of both political parties. What they are about is saying that anyone in an underserved area can walk into that facility and get health care, either

Medicaid, Medicare, private insurance, or a sliding scale--if you don't have enough money, you pay on a sliding scale basis--and low-cost prescription drugs.

This is a very successful program that now provides health care to over 20 million Americans and it is a 40-year-old program, again supported widely in the House and the Senate.

I am pleased that in the Senate bill, it recognizes the importance of both federally qualified community health centers and the National Health Service Corps. The National Health Service Corps is a long- established Federal program which says to people in medical school: We are prepared to provide debt forgiveness to you--on average, I know in Vermont, people are coming out $150,000 in debt--if you are prepared to work in primary health care in an underserved area.

In the Senate bill we recognize the importance of the federally qualified community health centers and the National Health Service Corps. In fact, our bill calls for authorization levels that, if appropriated, would enable the Community Health Centers Program to expand to every underserved area within 5 years, and would result in supporting at least 40,000 more primary care professionals in the next 10 years--doctors, nurses, dentists.

But we can and must improve the Senate bill. I favor very strongly the language in the House bill which calls for a dedicated trust fund with mandatory annual spending for community health centers and the National Health Service Corps. In other words, in the Senate we have authorized funding. The House has established a trust fund to actually pay for it. The Senate bill contains authorization levels that would be sufficient to fund a community health center in every underserved area in America and thus provide primary health care to 60 million more people by the year 2015. These are people who do not have to go into the emergency room, they don't have to go into the hospital because they are sicker than they should have been. They are going to get timely, cost-effective health care at a community health center.

Therefore, let me be very clear: I favor the language in the House bill which includes community health centers in its Public Health Investment Fund and guarantees mandatory funding for health centers totaling $12 billion over the next 5 years. This is in addition to the $2.2 billion current annual appropriation for community health centers which, it is anticipated, would also continue to be appropriated in each of the next 5 years. While this House funding level will not achieve a community health center in every underserved area, it will take us very far toward that goal, bringing primary care health services to some 40 million citizens living in underserved areas. Also in the House bill there is appropriated money to greatly expand the National Health Service Corps.

In the middle of all this discussion on health care, health insurance, let us not forget a few basic points. Sixty million Americans do not have access to a doctor. We need a revolution in primary medical care. We need to make sure we have the physicians, nurses, and dentists who are going to get out in underserved areas. The Senate bill provides authorization. The House bill provides a trust fund for community health centers and for disease prevention in general. My strong hope--and I am going to do everything I can to make sure it happens--is that the Senate adopts the House provisions.

If we are serious about providing health care to all Americans, we have to expand community health centers, we have to make sure there are primary health care doctors, dentists, nurses out there.

In addition, we need to focus on disease prevention. I know my colleague from Iowa has worked very hard on that. So we have to support the trust fund in that area.

I yield to my friend from Iowa.

Let me mention to my friend, in the State of Vermont, the poorest region of our State borders on Canada. It is called the Northeast Kingdom, in the northeast part of the State. For 30 years we have had a number of community health centers in that region. Do you know what? Amidst all of the poverty, all of the unemployment, all of the economic problems, we do not have a problem in terms of primary health care in the poorest area of the State of Vermont precisely because of these community health centers, which you indicate address dental care, which we often forget about, mental health counseling, we forget about, low-cost prescription drugs.

I look forward to working with the chairman of the HELP Committee and others to make sure we fund the kind of revolution we need in disease prevention, in primary health care, which at the end of the day improves people's health, keeps them out of the emergency room, keeps them out of the hospital, saves us money.

Study after study: Saves us money.

I ask unanimous consent for 2 minutes more.

Let me concur. In the State of Vermont we have gone from 2 to 8 with 40 satellites. Over 100,000 people in Vermont are now accessing community health centers for their primary health care.

The other point we don't often make about community health centers is they are democratically run, they are run by the communities themselves. My experience is exactly that of the Senator from Iowa. They are community health centers.

In rural areas it is not rich or poor. By and large, most of the people, regardless of income, go there. The doctors are there for a long time. The dentists are there. It is, in fact, in the best sense of the word, a community health center open and accessed by all people. People take responsibility for it because it is democratically run. It is a program--one of the bright shining stars of public health in America. I hope to work with the chairman of the HELP Committee to make sure these

programs are funded adequately in this bill and that we adopt the language in the House, which goes a long way.

I yield the floor.

I thank the Senator very much and yield the floor.

I am going to speak on something other than health care. I thank my friend from Montana for yielding.

Confirmation of Federal Reserve Chairman

Mr. President, what I want to touch upon is my strong belief that Ben Bernanke should not be reappointed for a second term as Chairman of the Federal Reserve. In that regard, I placed a hold on his nomination.

Everyone in this country understands we are in the midst of the worst economic crisis since the Great Depression. We are looking at 17 percent of our people being either unemployed or underemployed. We are looking at average length of unemployment being longer than it has been since World War II. We are looking at a situation where, over the last 8 or 9 years, median household income has declined by over $2,000. We are looking at a situation where, according to USA Today, September 18, 2009:

The incomes of the young and middle aged, especially men,

have fallen off a cliff since 2000, leaving many age groups

poorer than they were even in the 1970's.

What we are seeing is a long-term trend resulting in the collapse of the middle class, an increase in poverty, a growing gap between the rich and everybody else. Then, to make a very bad situation worse, as a result of the greed, irresponsibility, and illegal behavior of Wall Street, we are now in a terrible economic decline.

The American people voted overwhelmingly last year for a change in our national policies and for a new direction in the economy. After 8 long years of trickle-down economics that benefited the very wealthy at the expense of the middle class and working families, the people of our country demanded a change that would put the interests of ordinary people ahead of the greed of Wall Street and the wealthy few. What the American people did not bargain for was another 4 years for one of the key architects of the Bush economy, Federal Reserve Chairman Ben Bernanke.

The Chairman of the Federal Reserve--and the Federal Reserve itself-- has four main responsibilities. I want the American people to determine whether they believe the Fed has, in fact, succeeded in fulfilling these obligations. Here they are, four main responsibilities:

No. 1, to conduct monetary policy in a way that leads to maximum employment and stable prices. Maximum employment? When you have 17 percent of your people unemployed or underemployed, I do not think the Fed or all of us, any of us, have succeeded in that area.

No. 2, to maintain the safety and soundness of financial institutions. Obviously, that has not been the case either.

No. 3, to contain systemic risk in financial markets.

No. 4, to protect consumers against deceptive and unfair financial products.

Not since the Great Depression has the financial system been as unsafe,

unsound, and unstable as it has been during Mr. Bernanke's tenure. More than 120 banks have failed since he has been Chairman, and the list of troubled banks has grown from 50 to over 416.

Mr. Bernanke has failed to prevent banks from issuing deceptive and unfair financial products to consumers. Under his leadership, mortgage lenders were allowed to issue predatory loans that they knew consumers would be unable to repay. This risky practice was allowed to continue long after the FBI warned, in 2004, of an epidemic in mortgage fraud.

Here is what the bottom line is. The bottom line is that the key responsibility of the Fed is to maintain the safety and soundness of our financial institutions, and they failed. They failed. As a result of the greed and speculation on Wall Street--which the Fed should have been observing, which the Fed should have acted against, which the Fed should have warned the American people and the Congress about--they did nothing and our financial system went over the edge.

Then, after not doing their jobs as a watchdog, not fulfilling their obligation to protect the safety and soundness of our financial system, the financial collapse occurred, and what happened? What the Fed did is provide not only--not only did Congress put $700-plus billion into the bailout, the Fed provided several trillion dollars of zero-interest loans to large financial institutions. When I asked Chairman Bernanke which financial institutions received these zero-interest loans, the answer was: I am not going to tell you. Not going to tell you.

The reason Congress, against my vote, bailed out Wall Street is they were too big to fail. Large financial institutions were too big to fail. Since the collapse, three out of the four largest financial institutions have become even larger. So the systemic danger for our economy is even greater today than it was before the bailout.

The American people want a new Wall Street. They want a Wall Street which begins to respond to the needs of small business, so we can begin to create jobs, not just to Wall Street's outrageous executive compensation.

Let me suggest some of the things I think a Fed Chairman should be doing, things Mr. Bernanke is not.

No. 1, today, bailed out financial institutions are charging consumers 25 or 30 percent interest rates on their credit cards. The Fed has the power to stop that, to put a cap on interest rates. That is what they should be doing.

The Fed has the power to demand that bailed-out institutions provide loans at low interest rates to small and medium-sized businesses so we can begin to create the kinds of jobs that are desperately needed in this country. That is not what Mr. Bernanke has done.

The Fed has the power now to do what is taking place in the United Kingdom, something that many economists are demanding, and that is to start breaking up these large financial institutions which are too big to fail. In my view, if an institution is too big to fail, it is too big to exist. We have to start breaking them up, not allow them to get even larger. The Fed has chosen not to do that.

We need transparency at the Fed. I am the author of a GAO audit of the Fed, which now has 30 cosponsors, which I hope we will pass. But at the very least, if the taxpayers of this country are putting at risk trillions of dollars being lent out to large financial institutions, we have a right to know which institutions are receiving that money and under what terms.

Let me conclude by saying this: This country is in the midst of a horrendous economic crisis. Millions of families all over this country are at their wit's end. They are suffering. They are trying to figure out how they are going to keep warm this winter, how they are going to pay their bills. The time is now for a new Fed, for a new direction on Wall Street, for a Wall Street which is helping our productive economy create decent-paying jobs, not a Wall Street based on greed, only for themselves, whose goal in life is to make as much money as possible for their CEOs.

We need a new Fed, we need a new Wall Street, and we surely need a new Chairman of the Fed. My hope is that President Obama will give us a new nominee and not Mr. Bernanke.

I yield the floor.