Floor Statements

Mr. President, I had a chance to listen to my good friend, the Senator from Illinois; his remarks about why the bill before the Senate is going to reduce costs and pay down on the national debt. Now, that is the Senator from Illinois. I am the Senator from Iowa. But I would like to not refer to my judgment about this bill right now. What I would like to refer to is the judgment outlined in a report that was issued today from the Chief Actuary of the Centers for Medicare & Medicaid Services in the Department of Health and Human Services, a professional person who calls it like it is. That is his responsibility.

Remember, I am quoting from a report that was just given today about this 2,074-page bill we have before us, and that my friend from Illinois was just speaking very favorably about. So I am going to talk about somebody in the executive branch of government, under the President of the United States, who says this about this reform bill-- that it will cost more than the status quo. The Chief Actuary of the Centers for Medicare & Medicaid Services issued a report on Senator Reid's bill which shows that health care costs would go up, not down, under his bill. The Chief Actuary warned that the Democrats' health care bill would increase health care costs, threaten access to care for seniors, and force people off their current coverage.

In other words, the administration's own Chief Actuary conclusively demonstrates that the Democrats' rhetoric does not match the reality of the bill. The cost curve would bend up, not down. National health expenditures would increase from 16 percent of GDP to 20.9 percent under the Reid bill. The Chief Actuary concluded that the Federal Government and the country would spend $234 billion more under the bill than without it. The Chief Actuary also says that the bill ``jeopardizes access to care for beneficiaries'' because of the bill's severe cuts in Medicare.

Quoting the Chief Actuary:

Providers for whom Medicare constitutes a substantive

portion of their business could find it difficult to remain

profitable and . . . might end their participation in the

program (possibly jeopardizing access to care for

beneficiaries).

Then it speaks about the savings in the bill being unrealistic. The Actuary says that many of the Medicare cuts ``are unrelated to the providers' costs of furnishing services to beneficiaries.'' It is therefore ``doubtful'' that providers could reduce costs to keep up with the cuts.

Then the Chief Actuary speaks about new taxes costing consumers $11 billion per year. The new taxes in the Reid bill would increase drug and device prices and health insurance premiums for consumers. The Actuary estimates this would increase costs on consumers by $11 billion per year, beginning in 2011--that is 3 years before most benefits kick in.

Then the Actuary speaks about health care shortages, that these health care shortages are ``plausible and even probable,'' particularly for Medicare and Medicare beneficiaries. Because of the increased demand for health care, the Actuary says that access-to-care problems-- again these words ``plausible'' and even ``probable'' under the Reid bill. The access problems will be the worst for seniors on Medicare and low-income people on Medicaid. The Actuary says ``providers might tend to accept more patients who have private insurance with relatively attractive payment rates and fewer Medicare and Medicaid patients, exacerbating existing access problems for the latter group.''

Premiums for the government-run plan would actually be higher than under private plans. Agreeing with the Congressional Budget Office, the Chief Actuary said that because the government plan would not encourage higher

value health care and it would attract sicker people, premiums for the government-run plan would be 4 percent higher than for the private insurers.

Then there is a point about employers dropping coverage. The Chief Actuary concluded that 17 million people will lose their employer- sponsored coverage. Many smaller employers would be ``inclined to terminate their existing coverage'' so their workers could qualify for ``heavily subsidized coverage'' through the exchange.

Then it speaks, lastly, about the long-term health care part of this bill called the CLASS Act. The CLASS Act stands for Community Living Assistance Services and Support, C-L-A-S-S.

The Chief Actuary has determined that the CLASS Act long-term care insurance program faces ``a significant risk of failure'' because the high costs will attract sicker people and lead to low participation. Even though premiums would be $240 a month, the policy would result in ``a net Federal cost in the long term.''

I think quoting the Chief Actuary is a very good way to bring attention to the shortcomings that, on this side of the aisle, we have tried to discuss about the 2,074-page bill. Members on this side of the aisle have shown that the Reid bill will bend the health spending curve the wrong way over the next year and that the Reid bill cuts Medicare by $\1/2\ trillion and jeopardizes seniors' access to care. So, again, quoting from the Health and Human Services Chief Actuary's analysis confirms the dangerous consequences of the 2,074-page Reid bill.

I would like to highlight some of the findings in a more encompassing way than I just did, quoting the Chief Actuary.

First, contrary to what Members on the other side of the aisle claim, the Chief Actuary's report confirms that the Reid bill bends the cost curve the wrong way. According to the HHS Chief Actuary, over the next 10 years--and this chart highlights it--``total national health expenditures under this bill would increase by an estimated total of $234 billion.'' And a good portion of the increase in national health expenditures would be caused by the so-called fees in this bill on medical devices and on prescription drugs and on health insurance premiums.

Here we have a chart where the Chief Actuary found that ``. . . fees would . . . be passed through to health consumers in the form of higher drug and device prices and higher insurance premiums . . .'' This would result in ``. . . an associated increase of approximately $11 billion per year in overall national health expenditures.'' This refutes claims from the other side that the so-called fees won't be passed on to consumers. And this analysis clearly refutes claims from the other side that the Reid bill saves money.

Next, the Chief Actuary also confirms that the Reid bill jeopardizes beneficiary access to care. The Chief Actuary tallied up around $493 billion in net Medicare cuts, and he raised concerns in particular about two categories of these Medicare cuts.

First, the report warns about the permanent productivity adjustments to annual payment updates. These productivity adjustments ``automatically cut annual Medicare payment updates based on productivity measures for the entire economy,'' not just for that section of health care part of the economy.

The Chief Actuary confirms that these permanent cuts would threaten access to care. Referring to these cuts, he wrote that ``. . . the estimated savings . . . may be unrealistic'' and ``. . . possibly jeopardizing access to care for beneficiaries.''

``It is doubtful that many could improve their own productivity to the end achieved by the economy at large.'' This is a direct quote from the Chief Actuary's report. He goes on to say, ``We are not aware of any empirical evidence demonstrating the medical community's ability to achieve productivity improvements equal to those of the overall economy.''

In other words, basically he is saying this: If you are going to make a judgment that you are going to cut health care costs and that productivity has to be measured by the entire economy, you can't take the entire economy and apply it to a small segment of the economy-- health care--and expect it to be fair and expect that small segment of the economy to be as productive and equal the productivity of the entire U.S. economy.

You have to listen to these people who are professionals in these areas. The Chief Actuary is a professional. In fact, the Chief Actuary's conclusion is that it would be difficult for providers to even remain profitable over time, as Medicare payments fail to keep up with the cost of caring for beneficiaries.

Referring to this chart, ultimately, here is the Chief Actuary's conclusion: that providers who rely on Medicare might end their participation in Medicare, ``. . . possibly jeopardizing access to care for beneficiaries.'' That is right out of the Chief Actuary's report, is where that quote comes from.

He even has numbers to back up these statements. His office ran simulations of the effect of these drastic and permanent cuts. Here we have the quote. Based on the simulations, the Chief Actuary found that during the first 10 years, ``. . . 20 percent of Medicare Part A providers would become unprofitable . . . as a result of productivity adjustments.

This is going to be horrible on rural America where we already have difficult times recruiting doctors and keeping our hospitals open. As I said, it is difficult to keep up with these productivity adjustments by our providers. It is for this reason that the Actuary found that ``reductions in payment updates . . . based on economy-wide productivity gains, are unlikely to be sustainable on a permanent annual basis.'' That is right out of the report of the Actuary.

The second category of Medicare cuts the Chief Actuary raises concerns about would be imposed by the new independent Medicare advisory board created in this 2,074-page bill. This new body of unelected officials would have broad authority to make even further cuts in Medicare. These additional cuts in Medicare would be driven by arbitrary cost growth targets based on a blend of general economic growth and medical inflation. This board would have the authority to impose further automatic Medicare cuts, even absent any congressional action.

The Chief Actuary gives a reality check to this proposal. He shows how tall an order the Reid bill's target for health care cost growth actually is.

Again quoting the Actuary:

Limiting cost growth to a level below medical price

inflation would represent an exceedingly difficult challenge.

He points out in this analysis that Medicare cost growth was below this target in only 4 of the last 25 years. Just think--what this 2,074-page bill is trying to accomplish is something that has been accomplished in only 4 out of the last 25 years.

The Actuary also points out that the backroom deals that carved out certain types of providers would complicate this board's effort to cut Medicare. So, to this analysis:

The necessary savings would have to be achieved primarily

through changes affecting physician services, Medicare

Advantage payments, and Part D.

So providers, such as hospitals, will escape from this board's cut at the expense of doctors, Medicare Advantage plans, and higher premiums imposed on beneficiaries for their Medicare drug coverage, Part D of Medicare. If we survey the Nation's seniors, I doubt very much they would say that raising their premiums for Medicare drug coverage is what they would call health care reform.

This board, which can cut reimbursements, is guaranteed to have to impose these additional Medicare cuts. In other words, they can do it.

According to the Chief Actuary's analysis of the Medicare cuts in the Reid bill, even though the Medicare cuts already in the Reid bill are ``quite substantial,'' they would--the savings ``would not be sufficient to meet the growth rate targets.'' This means the board will be required by law to impose even more Medicare cuts, in addition to the massive Medicare cuts already in the bill.

This bill imposes a $2\1/2\ trillion tab on Americans. It kills jobs with taxes and fees that go into effect 4 years before the reforms kick in.

It kills jobs with an employer mandate. It imposes $\1/2\ trillion in higher taxes on premiums, on medical devices, on prescription drugs and more. It jeopardizes access to care with massive

Medicare cuts. It imposes higher costs. It raises premiums. It bends the growth curve the wrong way; in other words, up instead of down. This is not what people have in mind when they think about health care reform.

There is another aspect to this bill that I wish to go over. I hope the third time is the charm. I hope this time the other side of the aisle will understand that the Reid bill increases taxes on middle- income families, individuals, and single parents. That is because contrary to the claims made by the other side of the aisle, the Reid bill clearly raises taxes on middle-income Americans. We have data, not from this Senator, but as I quoted previously the expertise of the Chief Actuary, I want to quote the expertise now of the Joint Committee on Taxation, professionals who are blind to politics, who judge things and call them like they see them. Yesterday I pointed out how the same Joint Committee on Taxation data led my Democratic friends to proclaim that the Reid bill provided a net tax cut to all Americans. We have this distribution chart I used previously to show that that net really is not net.

There is no question that the bill does provide a tax benefit to a group of Americans, a relatively small group. A much larger group, however, will see their taxes go up. Most, if not all in this group, will not benefit from the government subsidy for health insurance. That is part of this 2,074-page bill. As a result, the generous subsidy that is in that bill that is going to a small group of Americans cannot be used by this larger group to offset their increased tax liabilities. The other side, however, wants to spread the large tax benefit that is going to this small group of Americans to everybody; in other words, all Americans, even among those Americans who are not eligible to receive the subsidy, and then somehow claim that all Americans are receiving a tax cut. How can a person receive a tax cut if they are not receiving some type of tax benefit?

Yes, the data shows that some will receive a benefit, but the data also shows that the others will see a tax increase. I have highlighted in yellow these various figures, individuals and families who will see a tax increase. In general, these individuals and families are not receiving the subsidy for health insurance. This means they have no government benefit to offset their new tax liability. The most important point I want to make--for the third time--is that these tax increases fall on individuals making more than $50,000 and families making more than $75,000. Again, I highlighted this group on the Joint Committee on Taxation chart.

The Joint Committee distributed in this chart three separate tax provisions: the high-cost plan tax, the medical expense deduction limitation, and the Medicare payroll tax. Among these tax provisions, the high-cost plan tax seems to be garnering the most attention and also tremendous opposition. I don't have to explain who the opponents of this tax increase are. Everybody knows. In fact, yesterday I had representatives of the Iowa Education Association, the teachers of Iowa, saying they are against that high plan tax because it is going to hurt Iowa teachers. So if this provision, the high-cost plan tax, were to drop out of the Reid bill for one reason or another--and this bill is still being written in secret or at least changes in this 2,074-page bill are being written in secret so who knows what is going to happen to this highly controversial thing--if it is taken out, some Members may feel they have successfully shielded the middle class from a tax increase. Unfortunately, for those Members who may be hopeful of this, lesser known tax provisions that are likely to stay in the changes that come through the Democratic health care reform product would still raise taxes on the middle class.

Again, don't take my word for it. The Joint Committee on Taxation tells us so. Specifically, that committee sent a letter to Senator Crapo stating that tax provisions such as the cap on flexible savings accounts, the elimination of tax reimbursements for over-the-counter medicines and, most importantly, the individual mandate excise tax penalty will increase taxes on people making less than $250,000. That happens to be middle-class individual, middle-class families, and middle-class single parents.

I ask unanimous consent to have printed in the Record that letter.

In closing, let me turn to one more chart the Joint Tax Committee has provided. This chart shows the effect on the medical expense deduction limitation. This tax increase is just one of the many tax increases likely to stay in the new Democratic proposal. On this chart, which is for the year 2019, because that is when this bill is fully implemented, we see positive dollar figures. I have highlighted these dollar figures in yellow. For those who may not be able to see, I will reiterate that this chart only has positive dollar figures on it. But remember, as I explained yesterday, when we see positive dollar figures from the Joint Committee on Taxation, that committee is telling us that taxes for these people are going to go up. That means for all of the tax returns listed on this chart, taxes will be going up for each. And this tax increase, the medical expense deduction limitation, reaches as low as someone making $10,000 a year.

Maybe some of these low-income individuals and families who will see a tax increase under this provision will receive a subsidy for health insurance. These people may be able to offset this new tax liability. But you can bet your bottom dollar that a large portion of the middle- income individuals and families are not receiving a subsidy. This means that this tax liability highlighted in yellow cannot be offset by the government benefit.

My Democratic friends cannot escape that fact. Even if my friends drop some of the tax provisions in the current Reid bill, many tax provisions will most likely remain. And those tax provisions will increase taxes on middle-class Americans. This not only breaks President Obama's pledge, but it will arbitrarily burden middle-class Americans for years to come.

I yield the floor.

Mr. President, my friends on the other side of the aisle have consistently stated that this 2074-page Reid bill, according to the Joint Committee on Taxation, is a net tax cut. I want to put emphasis throughout my remarks on the word ``net.''

Yesterday a chart was used to illustrate this point. This chart had multiple bars with dollar figures. For example, in 2019 the chart showed a $40.8 billion net tax cut. My Democratic friends said this number came from the Joint Committee on Taxation, a very responsible, intellectually honest group.

Unfortunately, the chart my friends were using was not entirely clear on how they came up with this net tax cut for Americans. So it was natural for most of the fellow Senators and the country at large to wonder how my Democratic friends got this number. They said show me the data.

To clear up any confusion, right here is the Joint Committee on Taxation table that the Democrats relied on to claim that the Reid bill results in a net tax cut. Here it is. We can see the negative $40,786, for example. That is the figure that was used. As the chart indicates, these dollar amounts are in the millions, so $40,786 million. The Joint Committee on Taxation says it this way: This means negative--the negative mark there--negative $40.8 billion.

My friends on the other side unfortunately did not explain what was going on here. It appears my friends simply made an assertion that they hoped many of us and those in the media would believe. But I cannot let my Democratic friends get off the hook this easily. Why? Because the entire story is not being told, so let me take a moment to explain.

First, in simplest terms, where you see negative numbers on this chart, the Joint Committee on Taxation is telling us there is some type of tax benefit going to the taxpayers. So this group and these groups here, wherever there is a negative here, those are tax benefits to the benefit of the taxpayers.

For example, families making $50,000 to $75,000 have a negative of $10,489 in their column. This means the Joint Committee on Taxation is telling us that this income category is receiving $10.4 billion in tax benefits.

I hope you will listen closely. When we see a negative number on this chart, the Joint Committee on Taxation tells us there is a tax benefit so, conversely, where we see a positive number the Joint Committee on Taxation is telling us that these taxpayers are seeing a tax increase. I have actually enlarged those numbers, the number of tax returns and the dollar amounts where there is a positive number for individuals and families. Again, these positive numbers indicate tax increase.

My friends have said that all tax returns in this chart are receiving a net tax cut. If that were so, why aren't there negative numbers next to all of the dollar amounts listed? Because not everyone in this chart is receiving a tax cut, despite what my friends have said. Quite to the contrary, a group of taxpayers is clearly seeing a tax increase and this group of taxpayers in middle income is seeing tax increases.

I didn't come down to the floor to say my friends on the other side of the aisle are wrong. After all, you can see here the negative $40,786 million figure they used is right there, out in the open. What I am doing is clarifying that my Democratic friends cannot spread this $40.8 billion tax cut across all the affected taxpayers on this chart, and then say that all have received a tax cut.

You want to know why. Because this chart, produced by the nonpartisan Joint Committee on Taxation, shows that taxes go up for those making more than $50,000 and families making more than $75,000. It is right here in the yellow, as you can see.

The numbers obviously do not lie. I say the nonpartisan Joint Committee on Taxation, I think everybody agrees, is very intellectually honest. So let me give you my read on what the Joint Committee on Taxation is saying here as evidenced by the figures on the chart.

First, there is a group of low- and middle-income taxpayers who clearly benefits under the 2074-page bill that is before the Senate. They benefit from the government subsidy of health insurance. This group, however, is relatively small.

There is another much larger group of middle-income taxpayers who are seeing their taxes go up due to one or a combination of the following tax increases: the high-cost plan tax increase, which actually is a brandnew tax; the medical expense deduction limitation, which used to be 7.5 percent, and now before you can deduct you have to have 10 percent of your income be medical expenses or you don't deduct anything, so that is a tax increase; and then a Medicare payroll tax increase, where everybody is going to pay--well, everybody over a certain income is going to pay an additional half a percentage point or, if you are self-employed, pay 1 percent more of payroll tax. In general, this group is not benefiting from the government subsidy. After all, how can a taxpayer see a tax cut if they are not even eligible for the subsidy?

Also, there is an additional group of taxpayers who would be affected by other tax increase provisions in the Reid bill that the Joint Committee on Taxation could not distribute in the way people are distributed on this chart. These undistributed tax increases include, among others, the cap on Federal savings--flexible savings accounts. Then there is a tax on cosmetic surgery.

My friend from Idaho, the author of the amendment before us, Mr. Crapo, recently received a letter from the Joint Committee on Taxation stating that this additional group exists and many in this group will make less than $250,000 and, hence, have a tax increase that is not accounted for here and also a tax increase if they are under $250,000. That is a violation of the President's promise in the last campaign that nobody under that figure would get a tax increase--only people over $250,000.

So you see, my Democratic friends cannot, No. 1, say that all taxpayers receive a tax cut--I have proven that here--and, No. 2, say that middle-income Americans will not see a tax increase under the Reid bill.

I yield the floor.

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

Mr. President, I have said, for the last 2 days, I was going to speak on the Dorgan amendment, a bipartisan amendment to allow the importation of drugs into the United States. I haven't done it until now, so I am glad to rise in support of this bipartisan amendment to add provisions of the Pharmaceutical Market Access and Drug Safety Act to this bill. That legislation is the result of a collaborative effort by Senators Dorgan, Snowe, McCain, and this Senator to finally make drug importation legal.

I have, for a long time, been a proponent of drug reimportation. In 2000, 2002, and 2003, I supported an amendment permitting the importation of prescription drugs into the United States from one country, Canada. This amendment is much broader than only Canada.

In 2004, the late Senator Kennedy and I worked together on a bill that would authorize drug importation, but it did not survive the partisan politics of this Chamber. I then introduced my own comprehensive drug importation bill in 2004. That was S. 2307, the Reliable Entry for Medicines at Everyday Discounts Through the Importation with Effective Safeguards Act. The REMEDIES Act is what the acronym finally spells out. In 2005, I combined my bill with a proposal sponsored by Senators Dorgan and Snowe. In 2007, we reintroduced a version of that legislation with the hope that our combined efforts would finally lower the cost of prescription drugs for all Americans. That is what we are still working together to do this very day. I thank Senator Dorgan for his leadership.

This time around, I should be confident that this effort will finally pass. Historically, Democrats claim to be champions of holding the big pharmaceutical companies accountable. Now we have a Democratic supermajority in the Congress and a Democratic President who has supported drug importation in the past. I am not as confident as maybe I should be. That is because the White House has participated in some back-room negotiations since the last time this legislation was brought before the Senate and then Senator Obama supported it. Behind closed doors, the Democratic White House found new friends in the pharmaceutical industry. Last summer, the head of the pharmaceutical lobbying group bragged that drug manufacturers had negotiated a ``rock- solid deal''--those are their words--with the present administration.

An article in the New York Times detailed the administration's deal with big drug companies. This quote comes from the New York Times:

Foreseeing new profits from the expansion of health

coverage, big drug companies are spending as much as $150

million on advertisements to support the President's plan.

But in 2008, when President Obama was campaigning for the position he now holds, he promised that:

We'll take on drug and insurance companies, hold them

responsible for the prices they charge and the harm they

cause.

Certainly, the President knows that a great way to hold drug companies accountable is to allow drug importation. In fact, in 2004, when he was a candidate to be a Member of this Chamber, he challenged his opponents to support drug importation. He said at that time:

I urge [my opponent] to stop siding with the drug

manufacturers and put aside his opposition to the re-

importation of lower-priced prescription drugs. . . .

But, unfortunately, it has been reported that during backroom negotiations at the White House, the big pharmaceutical companies have convinced the President to drop his strong support for drug importation.

The New York Times reports that:

On July 7--

Meaning this year--

Rham Emanuel, [President] Obama's chief of staff . . .

assured at least five pharmaceutical companies during a White

House meeting that there would be no provision in the final

health care package to allow the reimportation of cheaper

drugs. . . .

I thought we were going to hold drug companies accountable. I thought health care reform was supposed to drive down the cost of health care, including the cost of prescription drugs for all Americans. The Dorgan amendment is a commonsense, bipartisan approach to achieve both of these goals. Drug importation achieves these goals without imposing arbitrary fees, and without flexing the muscles of the Federal Government.

I have always considered this a free trade issue. I know most people see it as a health issue, and it is a health issue. But I come at it from the point of view that there are only a couple items Americans cannot buy in this country from anyplace else in the world they want to buy it. One class is pharmaceutical drugs, the other class is Cuban----

Mr. President, I ask unanimous consent for 4 additional minutes and that it come off the next block of time from our side.

So I see this as a free-trade issue. Imports create competition and keep domestic industry more responsive to consumers. In the United States, we import everything consumers want. So I ask again, why not pharmaceuticals? That is why it is a trade issue for me as much as a health issue. Consumers in the United States pay far more for prescription drugs than those in other countries. If Americans could legally and safely access prescription drugs outside the United States, then drug companies would be forced to reevaluate their pricing strategies. They would no longer be able to gouge American consumers by making them pay more than their fair share for research and development.

It is true that pharmaceutical companies do not like the idea of opening up America to the global marketplace. They want to keep the United States closed to other markets in order to charge higher prices here.

Based on the reports I just read, it seems that the White House has already sided with the drug manufacturers and promised them the ability to continue to gouge American consumers, otherwise known as the status quo.

The debate is not over. With the Dorgan amendment, prescription drug companies will be forced to be competitive and establish fair prices in America. The drug companies will try to find loopholes in order to protect their bottom line.

The Dorgan amendment would make such action illegal. It would not allow manufacturers to discriminate against registered exporters or importers. It would prohibit drug companies from engaging in any actions to restrict, prohibit, or delay the importation of a qualifying drug.

The Dorgan amendment would give the Federal Trade Commission the authority to prevent this kind of abuse. It develops an effective and safe system that gives Americans access to lower prices. Our effort goes to great lengths to ensure the safety of imported drugs. The Dorgan amendment requires that all imported drugs be approved by the FDA. It puts in place a stringent set of safety requirements that must be met before Americans can import drugs from that country.

The amendment requires all exporting pharmacies and importing wholesalers to be registered with the FDA and inspected. It gives the authority for the FDA to inspect the entire distribution chain for imported drugs. It sets very stringent penalties for violations of the safety requirements in this bill, including criminal penalties and up to 10 years imprisonment.

We need to make sure Americans have even greater, more affordable access to innovative drugs by further opening the doors to competition in the global pharmaceutical industry.

If my colleagues on both sides of the aisle are serious about bending down the cost curve of health care inflation--and doing it in that direction, the right direction--then they will support the Dorgan amendment, a bipartisan amendment.

I yield the floor.

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

Madam President, I know we have moved to the Omnibus appropriations bill to continue government, and the time is running out for the current authorization bill, and this brings us back to the authorization of spending, but it also takes us away from health care reform.

On this side of the aisle, we have been waiting for a long period of time to vote on some amendments that are now before the Senate, such as the Crapo motion which would send the bill back to committee to take out the tax increases that are in it. Then we also have the Dorgan amendment. I can understand why maybe the majority does not want to vote on Republican amendments, but I sure don't understand why they would object to voting on Senator Dorgan's amendment, a Democratic amendment, because there have always been more Democrats than Republicans for the Dorgan amendment, and quite frankly, I am in a position where I agree with that amendment. I am a cosponsor of it. I think we would have a great deal of bipartisan support for the Dorgan amendment. But now we are just automatically away from the health care debate and those amendments.

So I am wondering why we had to do this appropriations bill right now. I think there is growing realization that maybe public reaction, negative reaction to the legislation before us--remember that 2,074- page bill that is before us--the public is getting wise to what is in that bill and there is objection to it, and maybe now the majority party would like to have a little respite from that debate. So I thought I would come back to not the substance of the health care reform bill debate but to a lot of organizations that oppose it and why they oppose it, just to keep the public's attention that we on this side of the aisle feel the health care issue is very important.

As I travel around Iowa, I hear a lot of concern about out-of-control government spending. People are worried about all of the bailouts, the banks, and the automakers, the automakers such as General Motors being nationalized. They are worried about the rising rate of unemployment, which is 10 percent now. They don't see how we will ever dig ourselves out of the deficit hole we are in, a deficit that has been increased by $1.3 trillion since President Obama's inauguration.

As Senator McCain just pointed out, the bill that has now come before the Senate to fully fund the Federal Government has 12.5-percent increases in it. From that standpoint, it seems to me we are getting away from a commonsense principle that we ought to use around here on spending, and that is that spending shouldn't eat up any more than the economic growth of the tax base that is coming into the Federal Treasury to support that spending. Quite obviously, you can't have 12.5 percent increases in appropriations this year over last year, and last year was 9 percent over the previous year. You just can't sustain that. Common sense dictates against it. But what rules here in Washington is just a lot of nonsense.

So our constituents are confused. They are confused as to why, in the face of all these fiscal problems, some in Congress are now proposing $500 billion in tax increases. Tax increases are very bad for the economy. It is more difficult to get out of the recession as

you increase expenditures. They don't understand why some are proposing the largest Medicaid expansion since the program's creation. They want to know why they are proposing $500 billion in Medicare cuts to create an entirely new entitlement program that this country can't afford.

Nowhere are these worries and this confusion more evident than among business leaders of America because business is where jobs are created. Government does not produce wealth; government consumes wealth. So if you want to expand the economy, you do it through the private sector. That is where the resources of government come from. That is where the resources that sustain our people come from.

So whether it is a small business owner on Main Street or a CEO on Wall Street, the message is clear: Stop spending, get the economy back on track, and get people back to work.

Unfortunately, the health reform bill will not address any of these goals. In fact, it may just do the opposite. Don't take my word for it. Let's take a look at what the groups that represent American businesses are saying.

Let's start with the Chamber of Commerce representing 3 million American businesses. In a press release distributed November 19, 1 day after the release of the Senate bill, the Chamber called the Senate bill a ``Missed Opportunity to Enact Meaningful Reform.'' That was their title.

Let me go to a specific quote:

This bill still contains a government-run plan and an

onerous employer mandate, it taxes working Americans, slashes

Medicare, spends over a trillion dollars--and after all

this--CBO tells us 24 million Americans will still not have

health insurance.

That doesn't sound like the kind of reform that is going to help get the chamber members back on track hiring more workers so we can get this unemployment down. It sounds as though they will end up being forced to pay higher taxes and cut jobs. I am not an economist, but that certainly doesn't sound like a formula for getting this country out of the recession.

In fact, the chamber's press release says:

The Chamber believes the path to a healthier economy is to

cut taxes, not to raise them by $500 billion.

They go on to ask a question for which I still can't find an answer:

Why is there still no meaningful medical liability reform?

Is currying favor with the trial lawyers worth passing up $50

billion in CBO verified savings?

I think it is pretty clear that the Chamber of Commerce doesn't think this $2.5 trillion bill will cure what ails the U.S. economy.

Let's see what some other business groups have to say. The National Association of Manufacturers put out a press release the same day as the Chamber of Commerce, November 19. The National Association of Manufacturers is the Nation's largest industrial trade association. Their members build the machines that keep America running, so they should know a little bit about how to get our economy running again. Unfortunately, they see Senator Reid's bill as a step in the wrong direction. Like the Chamber and like pretty much every other business group, the National Association of Manufacturers has announced that they cannot support the pending bill.

I find it hard to believe that some Senators who claim to be probusiness can support a bill that is opposed by almost the entire business community--or am I missing something? How can some Democrats who claim to want to get people back to work support a bill that economists from the far right to the far left say will reduce wages and increase unemployment? It just doesn't seem to make sense.

Like other business groups, the National Association of Manufacturers is in favor of reform. Manufacturers realize that we need health reform to lower costs, increase access, and improve quality. But according to their press release, they cannot support a bill that will--this is their quote--``add massive financial burdens to businesses that are already struggling in this recession.'' They go on to express deep concern about huge tax increases that will hurt small business manufacturers, and they are worried that both the so-called public option and the massive Medicaid expansion will just end up shifting more costs and higher premiums to private businesses.

The National Association of Manufacturers ends their press release by saying:

Oppose the majority leader's bill and urge Senators to do

the same as it raises costs and ultimately will destroy jobs.

Again, I find myself asking how someone can claim to be probusiness but support a bill that is so strongly opposed by the business community.

Let's take a look at what small businesses have to say. Maybe that is where the answer is. You have to remember that small businesses create 70 percent of the net new jobs in America. In fact, it was Christina Romer, the President's top economic adviser, who said in a recent Webcast that health care reform will ``benefit small business--not burden it.''

Unfortunately, the National Federation of Independent Businesses, the voice of small businesses, doesn't seem to agree. After the release of Senator Reid's bill, the National Federation of Independent Businesses said this:

This kind of reform is not what we need to encourage small

business to thrive. We oppose the Patient Protection and

Affordable Care Act due to the amount of new taxes, the

creation of new mandates, and the establishment of new

entitlement programs.

Like the chamber and the National Association of Manufacturers, small businesses want and need reform, probably more so than even chamber members and the National Association of Manufacturers. But it doesn't sound as though the pending bill actually addresses the problems of small business. In fact, it sounds as though the pending bill simply creates a host of new problems--problems at a time when this country is coming back from the brink of the greatest economic downturn since the Depression.

The National Federation of Independent Businesses goes on to say:

There is no doubt all of these burdens will be paid for on

the backs of small businesses.

Over the coming weeks, I am sure some Senators are going to come down here and talk about all of the benefits for small businesses that are in this bill. But in the interest of honest debate, I hope they will at least mention in their remarks that despite all of the so-called benefits, this bill is still opposed by the voices of America's small businesses. It is still opposed by the National Federation of Independent Businesses. I could go on and list about half a dozen other business groups that oppose this bill. The Associated Builders and Contractors, the Independent Electrical Contractors, the International Franchise Association, the National Association of Wholesalers, the Small Business and Entrepreneurship Council, and the International Food Service Distribution Association--all of these groups recognize the devastating impact this bill will have on our economy.

We are facing the highest unemployment rate in 26 years. We have already seen the national debt increase by $1.3 trillion since inauguration or per household $11,535. The pending bill misses the mark on business' top priority, and that is lowering costs. Don't take my word for it. The Congressional Budget Office says the Reid bill bends the Federal spending curve further upward by a net of $160 billion between 2010 and 2019.

For these reasons, the pending bill is opposed by these organizations I have quoted: the National Association of Manufacturers, the Chamber of Commerce, the National Federation of Independent Businesses, as well as almost every other business group based in Washington, DC, or maybe, for all I know, they are based in other parts of the country, but they still follow legislation here in this city, in the Congress.

The business community has spoken, and their message is loud and clear. For Senators who want to bend the growth curve down--and that is what we all set out to do, but we don't have a bill before us that does it--this bill is not the answer. For those Senators who want to get people back to work, this bill is not the answer.

For those Senators who want to get this country's economy back on track, this bill is not the answer.

If you support American businesses--and American businesses are what provide the income into the Federal Treasury, whether it is corporate tax or income tax--it seems to me that if you have pride in American businesses and the jobs they create, you cannot support this bill.

I yield the floor.

Madam President, earlier today I explained to my fellow Senators, and hopefully to my friends in the media, that the Reid bill does not provide a net tax cut for Americans. Contrary to the Democrats' claims, that seems to be the situation. They claim there is a net tax cut. I hope I proved earlier today that it does not have a net tax cut. Some Americans are cut, but don't forget that some Americans have increases in taxes. I pointed directly to this data, as prepared by the Joint Committee on Taxation, to show that a group of middle-income taxpayers will see their taxes go up under the Reid bill, and that would be this class of taxpayers right here. I don't disagree with Democrats saying there is $40,786 million of tax cuts, but there are also tax increases for a large share of Americans.

I want to now build on those earlier remarks. As I stated, there is clearly a group of individuals and families who benefit from the government subsidy for health care. However, that group is relatively small. Another much larger group would see their taxes go up. So I want to take a minute to provide some statistics that we pulled from the data of the Joint Committee on Taxation looking at both the winners and the losers under the bill.

For the benefit of the public, the Joint Committee on Taxation is an intellectually honest group of professionals who are nonpartisan, and they give Congress information on the impact of policies we make here in our various committees or as individuals or the Senate as a whole.

According to this professional group, the Joint Committee on Taxation, out of those individuals and families affected by four major tax provisions under the Reid bill, individuals earning more than $50,000 and families earning more than $75,000 would see, on average, their taxes going up. Only individuals with incomes below $50,000 and families with incomes below $75,000 would, on average, see some tax relief on account of receiving subsidies for health insurance.

The data of the Joint Committee on Taxation indicates that in 2019, individuals earning less than $50,000 would, on average, receive tax relief through this subsidy equal to $875. Families earning less than $75,000 would, on average, receive tax relief equal to $2,031 from the subsidy. This so-called tax relief, however, is in the form of an advance refundable tax credit that is delivered directly to the insurance company providing health insurance coverage, not to the individual but signed, sealed, and delivered directly to the insurance company--100 percent of it. I repeat: not to the individual but to the insurance company. Clearly, this group is a winner under the Reid bill. But the same data from the Joint Committee on Taxation indicates that in 2019, individuals earning between $50,000 and $200,000 would, on average, see a tax increase of $593. That is for individuals. Now, let's go to families earning between $75,000 and $200,000. They would, on average, see a tax increase of $670.

So what does all this mean? This means the Reid bill does not cut taxes for all Americans. To the contrary, the Reid bill breaks Obama's promise not to tax individuals making less than $200,000 and families making less than $250,000 a year. And you just can't know how many times President Obama, during his Presidential campaign--whether in debates or in individual appearances when he was a candidate--made it very clear that nobody with under $200,000 a year in income was going to see a tax increase. To the contrary, the Reid bill breaks President Obama's pledge not to tax individuals making less than $200,000, and then a higher figure for families making less than $250,000.

Does the tax relief provided to individuals earning less than $50,000 and families making less than $75,000 represent a tax cut? Generally, no, because based upon the report of the Joint Committee on Taxation, of the $395 billion the government will spend on tax credits for health insurance--or subsidies for health insurance--$288 billion will be refundable, meaning individuals and families who have no tax liability will still receive the full benefit. The Joint Committee on Taxation tells us that the remaining $106 billion will go toward reducing real tax liability.

The Congressional Budget Office classifies a benefit provided to tax filers with no tax liability as government spending, not as a tax decrease. This is compared to a tax benefit that actually will reduce a taxpayer's tax liability. This means the $288 billion of government spending through the Tax Code cannot be considered a true tax reduction.

The Democrats count the $288 billion in government spending when claiming the Reid bill provides a tax cut. And the reason is if the Democrats do not count this government spending as a tax cut, they could not hide the fact that the Reid bill increases taxes.

Bottom line: The Reid bill does not provide a net tax cut. Instead, the bill

raises taxes and it raises taxes on individuals and families earning less than $250,000, contrary to Candidate Obama's presentation during the campaign that nobody below that figure would get a tax increase.

Check the data. No one can dispute it. It is right here in these figures. Everybody in the United States is represented by these figures here highlighted. They are the ones who are going to get a tax increase. That is the rest of the story.

I yield the floor.

Madam President, my friends on the other side of the aisle have taken to the floor to make the argument in favor of the Reid bill that it eliminates a so-called hidden tax. What is this so-called hidden tax? The other party argues that there is a hidden health tax that families pay in increased premium costs to cover the costs of caring for the uninsured. In short, when doctors and hospitals provide treatment to the uninsured they are forced to compensate for this ``uncompensated care'' and do so by charging more to private health insurers. The cost of this care that is shifted to the insurers is then passed on to health care consumers in the form of higher health insurance premiums. Unfortunately, this so-called hidden tax is often overstated.

Families USA conducted a study attempting to quantify the cost shift associated with uncompensated care. According to this study, about $43 billion in uncompensated care is shifted to private health insurance which led Families USA to conclude that there is a hidden tax of about $1,100 that families pay in increased premiums. A Kaiser Family Foundation study dissected the Families USA numbers and estimated that the total amount of uncompensated care shifted to private insurers was closer to $11 billion, making the so-called hidden tax around $200 for a family, compared to the $1,100 that Families USA said. Let me give some ground to my friends on the other side and assume that the hidden tax does equal that higher figure, $1,100, as compared to the Kaiser Family Foundation figure of $200.

The Democrats' bill does not get rid of the hidden tax entirely. Actually, this bill makes it worse. How? First, the Democrats' health care reform bill still leaves a large number of Americans uninsured. Specifically, the Reid bill leaves 23 million out of 54 million still without health insurance at the end of this decade, remembering that this bill does not actually take effect until 2014. So between 2014 and at the end of the budget window, we still have 23 million people without health insurance. At best, the reform in this 2,074-page Democratic bill cut the hidden tax in half; in this case, to about $500 for a family.

The Reid bill adds, however, new hidden taxes. These impose $67 billion worth of so-called fees on health insurance companies and self- insured arrangements beginning in 2010. The Congressional Budget Office, the Joint Committee on Taxation, the nonpartisan experts and official congressional scorekeepers have testified that these fees will be passed on to health care consumers.

The Congressional Budget Office and the Joint Committee on Taxation have further testified that this will result in higher insurance premiums for all Americans. The actuaries at Oliver-Wyman estimate that the fees imposed on health insurers would add $488 to the cost of the average family health insurance policy. A new hidden tax is also created as a result of the Medicaid expansion and Medicare cuts. The major cost shift in health care derives from the government programs, Medicare and Medicaid, which reimburse providers at rates roughly 20 percent to 40 percent lower than what private providers pay to the same doctors and hospitals.

President Obama understands that paying doctors below market rates leads to a cost shift. After all, in a townhall on health care reform, the President said:

If they're only collecting 80 cents on the dollar, they've

got to make it up somewhere, and they end up getting it from

people who have private insurance.

The Medicare and Medicaid cost shift will be increased significantly under the Democrats' health care reform bill. According to CBO's estimate, Medicaid will be increased by more than 40 percent, from 35 million to 50 million people by the end of the budget window in 2019. Additionally, the bill includes almost $\1/2\ trillion in Medicare cuts which will result in lower payments to providers.

The actuaries at Milliman Consulting studied the current cost shifting resulting from Medicare and Medicaid underpaying providers and found that this cost shift for Medicare and Medicaid totaled almost $89 billion per year, adding $1,788 to the current family health insurance policy. Increasing the current Medicare and Medicaid cost shift, as a result of this 2,074-page health reform bill before us, would add even more cost to a family health insurance policy.

The easier cost shift to address would be the $1,700 cost shift from defensive medicine. The Democrats do not address cost shift from defensive medicine which Dr. Mark McClellan, former head of CMS, and Daniel Kessler estimated adds $1,700 in additional cost per average family. Addressing this reform alone could save more than covering all of the uninsured.

So you see, the Democrats say their bill will eliminate the so-called hidden tax. My friends seem to come up short on that one. Also, my friends add new hidden taxes that will burden middle-class Americans.

I ask my friends to be transparent when they are talking about getting rid of the hidden tax. The Democratic health reform bill actually makes things worse.

I yield the floor.

Mr. President, I don't rise to add to what the Senator from New Jersey said. I just wish to take this opportunity to tell him I agree with him, and I appreciate his leadership on this issue over several years--even the years before he came to the Senate.

Often, I am asked in my State, because we can export so much agricultural stuff, if I would vote to open trade with Cuba. I said I am willing to open trade for Cuba when they give political freedom and economic freedom to the people of that country because this dictator has run Cuba into the most impoverished country in the world. Before he took over, they had a very viable middle class and they were a prosperous country.

I stand ready to help the Senator on what he is trying to do in that area.

Mr. President, I come to the floor at this point to give some breadth to a statement that was made on the floor earlier today. It was made by my friend, Senator Baucus. I don't take offense to what he said because I sensed a great deal of frustration in his statement. I will read what he said so you know what I am reacting to. The reason I don't take offense to what he said is because he and I have worked so closely together over 10 years, with one or the other of us being chairman of the Finance Committee, that we have such an understanding of each other.

Just prior to the remarks I am going to read, he had spoken positively about Senator Enzi and me. So I want my colleagues to know this statement is not made out of anger that I am going to give a rebuttal to.

Well, we kept working bipartisan--working together, for

days and days, hours and hours, and then, fortunately, Mr.

President, it got to the point where I'm just calling it as I

see it. I can't--I--one of my feelings is I'm too honest

about things. And it's--the Republicans started to walk away.

They pulled away from the table. They had to leave.

I ask you why? Why did that happen? And the answer is, to

be totally fair and above board, is--and above board, is

because their leadership asked them to. Their leadership

asked them to become disengaged from the process. I know that

to be a fact. Why did their leadership ask Republicans to

leave and become disengaged from the process? To be totally

candid, they wanted to score political points by just

attacking this bill. They were not here to help--help be

constructive, to find bipartisan solutions. They were for a

while, then when the rubber started to meet the road and it

came time to try to make some decisions, they left and began

to attack--and began to attack.

I wish to take a few minutes to respond to these remarks that I read. It was asserted, through these remarks on the floor, that some Republicans in the so-called Gang of 6 were directed by the Senate Republican leadership to cease participating in bipartisan talks. The Gang of 6 referred to the six bipartisan members of the Senate Finance Committee. On the Democratic side, the members were my friends, three chairmen, including Senator Baucus, Budget Committee chairman; Senator Conrad; and Energy Committee chairman, Senator Bingaman. All are senior members of the Democratic Caucus. On the Republican side, the three members included Senator Snowe, ranking member of the Small Business Committee; Senator Enzi, ranking member of the Health, Education, Labor, and Pensions Committee; and this Senator. Senators Snowe and Enzi are senior Members of the Republican caucus.

Chairman Baucus convened this working group with a singular goal of a bipartisan health care reform bill. We met for several weeks up in the Montana Room of Chairman Baucus's office. I would agree with the way participating Members have described these discussions. They were well informed, thoughtful, provocative, challenging, and frustrating all at the same time. But I would say that in the months we negotiated, there was never once that anyone walked away from the table. There was never once that there were any harsh words.

While we were engaged in those discussions, there was constant pressure from folks outside the room for us to reach a quick deal. That pressure came from the White House, it came from the Democratic leadership, it came from advocacy groups outside, and it came from many media folks covering the day-by-day meetings. To be fair, the Senate Republican leadership was very concerned about some of the directions the policy discussions were taking in the Gang of 6. That concern grew, particularly after the very partisan HELP Committee markup occurred. Senator Hatch left the original Gang of 7 because of the character and result of the HELP Committee markup.

Most important, the Senate Republican leadership was concerned that a bipartisan Finance Committee bill would be co-opted into a partisan floor bill, when the Democratic leadership merged the bills. Senators Snowe, Enzi, and I anticipated that concern.

To be fair to Senator Baucus, as he was negotiating with us, he tried to convince us that we would be very much a part of those merging of the bills. He offered that in good faith. I believe him. I even believe him today saying that. But seeing how neither the HELP Committee nor the Finance Committee was as involved as they should have been in what Senator Reid

put together in this 2,074-page bill, I wonder whether Senator Baucus could have, if we had a bipartisan agreement, actually carried out that guarantee.

From the get-go, we Republican members of the Gang of 6, to make sure we were a part of the process that I described, as Senator Baucus told us we would be, asked for assurances from the White House and from the Senate Democratic leadership on the next step in the legislative process, if we, in fact, did arrive at a bipartisan agreement.

I also found that many in the broader group of Republicans, who provided the bipartisan glue for the CHIP bill of 2008, had similar concerns. All Republicans had process concerns, such as where would it go once it left the Senate Finance Committee.

We wanted assurances, and here is what we wanted. The assurances requested boiled down to a good-faith promise that the bipartisan Finance Committee health care bill would not morph into a partisan health care reform bill when Majority Leader Reid merged the two committee bills. We wanted to make sure the bipartisan character of a bipartisan Finance Committee bill was going to be retained through these next steps. To do otherwise would be akin to getting on a bus and not knowing where the bus was going or how much the bus ticket would cost. Assurances were also requested with respect to a conference between the House and Senate. The assurances were similar to assurances requested by Senator Reid and made by the then-majority Republican leadership during the period of 2005 and 2006. The Democratic minority leader, at that time, made these assurances a condition to letting major regular order Finance Committee bills even go to conference.

As an example, take a look at the Congressional Record, and you will see the assurances made by then-Majority Leader Frist to then-Minority Leader Reid. These requests were made repeatedly to the Democratic leadership, publicly and privately, about how the postcommittee action of the bipartisan group would be handled in the merger with the HELP Committee bill. It was a focus of a July 8 lunchtime, face-to-face meeting at the majority leader's office, with Senators Reid, Baucus, Conrad, Bingaman, Snowe, Enzi, and myself. The bottom-line response from Senator Reid at that meeting was he needed 60 votes.

I guess, the implication was, despite the fact that the Democratic caucus contained 60 members then and now, Senator Reid didn't think it was possible to secure the votes of all members of his caucus. A restatement of the reality of the Senate rules was not the assurances the three Republican Senators--this one included--sought from Senator Reid.

Senator Reid, himself, recognized the validity of this request in an August 8 Washington Post article. I ask unanimous consent to have that article printed in the Record.

Mr. President, I will quote, in part, from the article:

The closer these negotiators move to striking a deal, the

more fraught the discussions become by issues of trust and

political will. Among Republicans, the pressure is especially

acute. All three GOP senators fear they will be sidelined

once the bill is approved at the committee level, with their

names invoked to demonstrate bipartisanship even as they're

left with no say over the final product as it is meshed with

the Senate health panel's version and then ultimately with

the House bill.

Republicans were also worried that the bipartisan product could be lifted into a partisan reconciliation bill. I quote further from that same Post article:

Reid said he already provided the Republicans with some

assurances, and added, ``I'll do more if necessary.''

Continuing to quote from the Post article:

He said of GOP concerns, ``I don't blame them.'' And he

added that, considering the political realities of the

Senate, with its large number of moderate Democrats, health-

care reform would have to gain significant bipartisan support

to cross the finish line.

President Obama and the Senate Democratic leadership set a deadline of September 15 for the bipartisan Gang of 6 to produce a proposal. If the proposal were not available by then, the President and Senate Democratic leadership made it clear the plug would be pulled on further bipartisan talks.

I point that out because that is very significant. A powerful member of the Senate Democratic leadership, the senior Senator from New York, made it crystal clear the Senate Democratic leadership would pull the plug. That member, who is very smart and articulate, made it as transparent as possible that the September 15 deadline was more important than a bipartisan deal.

I ask you to go back and look at the media reports. The Gang of 6 was unable to reach a deal on contentious issues such as abortion, the individual mandate, and financing issues by White House/Democratic leadership's deadline.

Chairman Baucus had to move forward. I respect the pressure my friend from Montana was under. I have been there myself. But the record needs to be correctly made that the September 15 deadline was not a Republican deadline. It was a deadline imposed by the White House and the Senate Democratic leadership. I might say that wasn't just the GOP deadline--it wasn't a deadline for the Gang of 6 either. I didn't sense, from the three Democratic members, that they agreed with that.

So the Senate Democratic leadership pulled the plug on the talks. Again, go check the public comments and press reports. They pulled the plug. Senator Enzi and I could not agree to the product at that point because of substantive issues that were resolved against us and the failure of the White House or Senate Democratic leadership to deliver on those process assurances that we asked for.

Senator Snowe did have substantive issues resolved sufficiently at the Finance Committee markup so that she could support the bill.

I might note today that I heard Senator Snowe caution the Democrats as she gave them the boost from her vote in the Finance Committee--that was right after the bill passed--she made it clear that her vote for later stages would depend in part on data on the key question of whether the product makes health care more affordable. Her letter to CBO dated December 3 lays out the issues in precision.

At the next stage of the process, the merged-bill stage, all of the Senate Republicans' worst fears were confirmed, but it was especially telling to Senator Enzi and me. My sense is Senator Snowe appreciated it more than any other member of our conference. The bottom line was that the majority leader's merged bill was constructed in such a partisan way that Senator Snowe's input was cast aside.

Let's be clear. Senate Republicans did not set deadlines. Senate Republicans did not threaten to go their own way if the deadlines were not met. Even today, the pending motion from this side of the aisle puts the question to the Senate this way: Take the bill back to the Finance Committee.

As the old saying goes, hindsight is 20/20. As I look back on the process, I make these observations: There was an uncanny disconnect between those inside and outside the room. Many on the outside, mainly from the left side of the political spectrum, seemed to want a reform deal just to have a deal. They did not seem to be that curious about the contents. Perhaps for some of those folks, it was a bit of an imperative to draw on the good will that any President has in the first few months of office.

For those of us in the room--meaning the room where the negotiations were going on--there was a realization that we were tackling, as Chairman Baucus has described it, an extremely complex set of issues. We learned very quickly that closing the loop on the policy issues, let alone finding political consensus, was not easy.

The pressure to close a deal by the July 4 recess was overwhelming. My friend, the chairman, wisely pushed back and said we would get a deal when we reached a bipartisan deal. The Group of 6 was unable to reach a deal on contentious issues such as abortion, individual mandate, and financing issues faced by the White House-Democratic leadership deadline. Chairman Baucus had to move. In my heart, I feel he would rather not have had that sort of pressure or make that decision. But that was not our deadline. It was a deadline imposed by the White House and the Senate Democratic leadership. They pulled the plug on the talks. Go check the public comments and the press reports. They pulled the plug. Senator Enzi and I could not agree to a product at that point because of the substantive issues that were very much involved.

I want to make it very clear, for this Senator, of the three Republicans who were negotiating, kind of in summary, that the Republican leadership, I think, had questions about a lot of things that were going on in those negotiations. But never once did Senator McConnell, my leader, say to me: Get out of there.

That is the impression that was left this morning.

I can only say that I think I have established a reputation in the Senate, particularly while I was chairman of the Senate Finance Committee, that I did not listen to either the White House or people in leadership necessarily when I thought a bipartisan compromise was the only way to get things done. I suppose there is a whole long list of things that I ought to write down before I make this statement, but I can only think of two or three right now that I can be sure of that I can say in an intellectually honest way that I stood up to the Bush White House when I was chairman of the committee.

They came out immediately for a $1.7 trillion tax cut in 2001. I made a decision early on that it was not good for the economy and it was not politically possible. So we passed a much smaller, in a bipartisan way, tax bill for that year. And yet it was the biggest tax cut in the history of the country.

In 2003, when the White House and House Republicans in the majority at that time said we had to have a $700 billion tax cut in addition to the tax cut that was passed in 2001, there were not votes in the Senate among just Republicans to get it done. To secure the votes to get it done, we had to limit it to half that amount of money, or just a little bit more than half that amount of money. And in order to get those votes, contrary to the $700 billion tax cut that the Bush White House wanted and the House Republicans wanted that we could not get through here, I said I will not come out of conference with a tax cut more than that amount of roughly $300 billion.

We got that done by just the bare majority to get it done. But I stood up to the White House, I stood up to the House Republican leadership who thought we should not be doing anything that was short of that full $700 billion.

There have been other health care bills very recently where I stood up against the White House and against our Republican leadership.

I think I have developed a reputation where I am going to do what is right for the State of Iowa and for our country. And I am going to try to represent a Republican point of view as best I can, considering first the country and my own constituency.

Then when it comes to whether people in this body or outside of this body might think that for the whole months of May, June, and July, and through August, with a couple meetings we had during the month of August, that we were dragging our feet to kill a health care reform bill, I want to ask people if they would think I wouldn't have better things to do with my time than to have 24 different meetings, one on one with Chairman Baucus, or that I wouldn't have more than something else to do than have 31 meetings with the Group of 6. These were not just short meetings. These were meetings that lasted hours. There was another group of people--Grassley, Baucus, and others, sometimes that included people from the HELP Committee and the Budget Committee. But we had 25 meetings like that. I wonder if people think we would just be meeting and spending all those hours to make sure that nothing happened around here. No. Every one of the 100 Senators in this body, if you were to ask them, would suggest changes in health care that need to be made. Even in that 2,074-page bill, there are some things that most conservative people in this country would think ought to be done.

We all know to some extent something has to be done about this system. We worked for a long period of time, thinking we could have something bipartisan. But it did not work out that way, and now we are at a point where we have a partisan bill.

That is not the way you should handle an issue such as health care reform. Just think of the word ``health,'' ``health care.'' It deals with the life and death of 306 million Americans. Just think, you are restructuring one-sixth of the economy.

Senator Baucus and I started out in January and February saying to everybody we met, every group we talked to, that something this momentous ought to be passing with 75 or 80 votes, not just 60 votes. Maybe one of the times the White House decided to pull the plug on September 15 may have come on August 5 when the Group of 6 had our last meeting with President Obama. He was the only one from the White House there and the six of us. It was a very casual discussion.

I said this before so I am not saying something that has not been said. But President Obama made one request of me and I asked him a question. For my part, I said: You know, it would make it a heck of a lot easier to get a bipartisan agreement if you would just say you could sign a bill without a public option. That is no different than what I said to him on March 5 when I was down at the White House, that the public option was a major impediment to getting a bipartisan agreement. Then he asked me would I be willing to be one of three Republicans, along with the rest of the Democrats, to provide 60 votes. My answer was upfront: No. As I told him, you can clarify with Senator Baucus sitting right here beside you, that 4 or 5 months before that, I told Senator Baucus: Don't plan on three Republicans providing the margin, that we were here to help get a broad-based consensus, as Senator Baucus and I said early on this year, that something this massive ought to pass with a wide bipartisan majority.

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

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

Mr. President, I need to correct the Record. In the part of my statement where I refer to the July 8 meeting with Senator Reid, it was only Snowe, Grassley, and Enzi, not the other Senators I named. So I wish to correct that for the Record.

Madam President, I thank the Senator from Montana for arranging that for me. I hope this afternoon to speak on the issue of importation of drugs because I support the Dorgan amendment. Right now I wish to address the issue of the Crapo motion to commit.

This generally deals with all of the tax provisions in this 2,074- page bill. If Senator Crapo prevails--and he should--the unrelated House bill, along with the Reid amendment, would be sent to the Senate Finance Committee. The Finance Committee, under the motion, would be empowered to return the bill to the full Senate with an amendment that eliminates the heavy taxes that are in this bill. Senator Crapo has discussed the impact of the Reid amendment on middle-class families. I will lay out all the taxes that are in this bill.

In farm country, many of us who work the land often observe big freight trains rumbling across the terrain. Sometimes they scare cattle, hogs, and other animals. Those freight trains are impressive in their power, in their speed, and now the length of the trains. It is very common to see a 100-car train, 150-car trains. The partisan force with which the majority is powering this bill through the Congress is equally as impressive as that of a freight train. The speed that is being displayed for such complex legislation is something to behold. Most importantly, the sheer number and breadth of the new taxes in this bill reminds me of a very long train.

Almost $\1/2\ trillion in taxes, fees, and penalties, and I think they all have the same economic impact, whether it is a tax, a fee, or a penalty--a negative impact on the economy. These taxes, fees, and penalties are so imposing, I am calling this 2,074-page bill the tax increase express.

The locomotive driving this train is health care reform, driven by the Democratic leadership. So we have the locomotive that drives this tax increase. I don't think the American public knows the bill would impose that much, $\1/2\ trillion worth of new taxes, new fees, and new penalties on the American people.

The American public, who supported President Obama with a majority of votes 13 months ago, heard the President loudly and clearly, and that is why they gave him such an overwhelming majority.

They understood our President pledged he would not raise taxes on people making less than $250,000 a year. Unfortunately, the Democrats' leadership bill would violate that clear pledge.

What are the tax increases and the fees and penalties in Senator Reid's amendment? Let me take a moment to highlight them because every locomotive needs power to run. The first power source, the first car of the tax increase express, is the so-called fees on health insurance companies, medical device manufacturers, and drug manufacturers.

That might not sound like something the grassroots of America would worry about--taxes on insurance companies, medical device manufacturers, drug manufacturers--because maybe they think businesses pay taxes. But businesses and corporations do not pay taxes, only people pay taxes. So when people find out they are going to be paying these, it puts a whole new light on what is a fee and what is a tax.

There have been numerous studies that have shown that these fees on, for example, health insurers will increase health insurance premiums. Some say premiums would increase by $488 for a family, other studies say $500. Most Members on the other side of the aisle take issue with these studies. They argue these studies were performed at the request of insurance companies or conducted by independent experts with ties to that same industry.

Let me ask my Democratic friends this: Do you question the work of the Congressional Budget Office and the Joint Committee on Taxation? Well, you should not because they are like a god around here. When the CBO says something is going to cost something, that stands, unless there are 60 votes to override it in the Senate. So most everything the CBO says stands. They have respect because of the intellectual honesty of their research and the nonpartisanship they have. So these agencies--the Congressional Budget Office and the Joint Committee on Taxation--have testified that these fees will actually be passed on to health care consumers. Check the record. No one can dispute it.

The Congressional Budget Office and the Joint Committee on Taxation have also testified that the fees will increase

health insurance premiums. Check the record. No one can dispute it.

My friends in the Democratic leadership may say, once their health reforms are in place, premiums will go down, net of the fees. They will hail a recent CBO report highlighting the winners but somehow ignoring the losers. They will say these fees will not affect premiums for the vast majority of Americans. But here is the flaw in that assertion. The Congressional Budget Office analyzed premium costs, what they are projected to be in 2016 under this legislation.

What about premium costs right now in the years before these programs take effect--2010 and 2013? Why is this question important? The answer is, these fees go into effect in the year 2010, not when most of the expenditures go into effect in 2014.

The majority of the Democratic reforms which are intended to lower costs do not go into effect until 2014--4 years from now. I ought to say that 10 times because that is very important to how this bill came out to be revenue neutral.

So we ought to look at what happens in the years 2010, 2011, 2012, and 2013. Premiums will go up. Why? Because, for one, the Democrats are adding costs to the health insurance you buy by imposing these fees on health insurers, and they are giving you no government assistance to help with these added costs.

I would ask my friends in the media, dig a little bit deeper on this point, and you ought to be reporting on it. Why? Because the American public does not understand that in the short term premiums will go up. Instead, the public is simply hearing some media reports on a portion of the premiums, in 2016 and beyond. Of course, that is a very long time from now. The American public does not want to wait for their premiums to go down, if they go down at all. It appears my friends in the Democratic leadership want the tax increase express to barrel through Congress before the public realizes what health care reform actually means; that is, higher premiums as early as 2010.

Let me turn to the second car of the tax increase express. This car is the proposal to restrict the eligibility criteria for claiming the itemized deductions for medical expenses. This proposal says you can no longer deduct expenses that exceed 7.5 percent of your adjusted gross income. Instead, you can only deduct expenses that exceed 10 percent of your adjusted gross income.

In plain English, this proposal limits tax deductions you can take for medical expenses. In other words, you will lose a portion of your tax deductions. Even the New York Times calls proposals that would take away a portion of your tax deduction a tax increase.

Mr. President, I ask unanimous consent that article from the New York Times, dated February 26, 2009, be printed in the Record.

In the top line, the article says: ``President Obama will propose further tax increases on the affluent to help pay for . . . health care reform.''

I am highlighting this article because the President is also proposing to take away a portion of a person's tax deduction. The President wants to limit the itemized deductions people making more than $250,000 a year can take. The only difference between the two proposals is the medical expense deduction limitation affects people who make less than $250,000 a year--the same class of people the President promised in the election he was not going to increase taxes on.

So, again, do not take my word for it. Data from the Joint Committee on Taxation tells us that in the year 2013, the largest concentration of taxpayers claiming the medical expense deduction will earn between $50,000 and $75,000--people who never thought they were going to have their taxes increased based upon what the President said during the campaign.

The analysis shows, a good number of taxpayers earning between $75,000 and $200,000 also claim the medical expense deduction.

My friends on the other side of the aisle will argue that their government-subsidized tax credit for health insurance will wipe clean any new taxes for those people below 400 percent of poverty. They will also argue that people purchasing insurance through the new exchange will be protected from catastrophic expenses as a result of annual out- of-pocket limits. For this reason, my friends on the other side argue those middle-class taxpayers will not need to rely on medical expense deductions.

I hate to break it to my colleagues, but the Congressional Budget Office--again, that god of Capitol Hill--estimates that in 2014 only 4 percent of Americans will be purchasing exchange insurance and only 3 percent of Americans will be receiving a tax credit. By 2019, when the Reid bill is in full effect, only 7 percent of Americans with exchange insurance will be receiving the tax credit. That leaves a heck of a lot of people below 400 percent of poverty with higher taxes.

What about those individuals and families above 400 percent of poverty? These people earn income below the President's magic $250,000 level, and somehow they do not qualify for this tax credit. What they do qualify for, though, is a tax increase. After all, there is reason why this proposal raises $15 billion over 10 years, and that is a heck of a lot of money.

Let me now turn to the third car of the tax increase express. This car is the high-cost plan tax. The Congressional Budget Office has consistently cited the two most powerful ways to bend the cost curve downward, meaning the cost curve of health care inflation: No. 1 is to cap the tax preference for employer-provided health coverage or the so- called exclusion; and, secondly, Medicare delivery system reforms.

A recent letter sent to the White House by respected economists also contends that placing a limit on high-cost employer plans would slow health care spending and reduce costs.

Well, some of my colleagues have come out squarely in support of a cap on the exclusion. That was an intellectually honest position. My friends, the chairman of the Budget Committee and the chairman of the Finance Committee, took the intellectually honest position. The Democratic leadership, however, has squarely opposed a cap on the exclusion. They argue that a cap on the exclusion would hurt middle- class workers.

But in a sleight of hand, this bill--this 2,074-page bill--and its authors, the Democratic leadership, came up with a proposal that would tax insurance companies for offering high-cost plans. It is a more complicated way of taxing the same workers. It is a sleight of hand because the Democratic leadership knows the tax will be passed through to the worker.

My friends simply did not want to say they were taxing the workers directly. So they have decided to tax those same workers very indirectly. In the end, the worker would be paying the tax, and these workers would be middle-income workers.

Again, do not take my word for it. The Joint Committee on Taxation testified before our very Senate Finance Committee that the high-cost plan tax would be passed on to whom--the workers.

Joint Committee on Taxation data also indicates that in 2019, 84 percent of the revenue generated from the high-cost plan tax comes from--guess who--individuals and families earning less than $200,000 a year, contrary to the President's promise in the last campaign that these folks would not pay any additional tax.

So whether you agree or disagree with the policy of limiting the tax benefit for employer-provided coverage, middle-class workers would see a tax increase.

Let's go to the fourth car of the tax increase express. This car is going to carry two new tax increases. The first tax increase is on workers who contribute to a flexible spending account, better known as an FSA.

Under the current tax laws, a worker may contribute to an FSA on a pretax basis and use those FSA contributions to pay for copays and deductibles tax free. Currently, there is no limit on how much a worker may contribute to an FSA. This 2,074-page bill, put together by Senator Reid, would limit the contribution amounts to $2,500. Statistics show, the average FSA contribution is $1,800 a year. So this $2,500 limit does not sound that bad, right? Well, I say wrong. A great number of workers who have serious illnesses contribute significantly more than $1,800 and, let me say, more than $2,500.

On average--on average--these workers whom I am talking about with serious health problems earn about $55,000 a year. If I were to connect the dots, I would see a tax increase on workers with serious illnesses who earn $55,000 a year. Well, here is how. These workers would now have to pay taxes on their FSA contributions in excess of $2,500. The Democratic leadership is taxing health benefits for the first time ever--at least this benefit for the first time ever.

The second tax increase in this fourth car is the elimination of the taxfree reimbursement for over-the-counter medicine. Under the current tax rules, payments for over-the-counter medicine may be reimbursed taxfree if a worker is covered under a flexible savings account or under a health savings account. This 2,074-page bill takes away that tax benefit.

The fifth car of the tax increase express is the new Medicare payroll taxes. Since the New Deal, the United States has put into place several social insurance programs. They are part of the social fabric of America. Included in those programs are Social Security, unemployment insurance, and Medicare. They are all founded on the social insurance concepts. As Senator Moynihan, when he represented New York, used to remind us, to ensure their constitutionality, these programs were designed to be financed with payroll taxes instead of insurance premiums. But to maintain the closest appearance possible to social insurance, the payroll tax looks a lot like a premium for insurance.

This analogy is very intentional. It is not accidental. It is bedrock to the sustainability and universality of social

insurance programs that we all support: Social Security on the one hand, Medicare on the other.

The Reid amendment breaks that precedent, muddies the premium analogy, and could start us on a tax-hike-only journey to dealing with our unsustainable entitlement programs.

Let me explain that. The way the payroll tax works now is that every worker pays in based on his or her salary, wages, or small business income. That is a single, simple, and consistent tax base. Also, one tax rate applies to that payroll tax base. Now, for the first time--for the very first time--an additional second tax rate will apply to the payroll tax base. Also, for the first time in the almost 45-year history of this great social insurance program, we have before us a proposal that creates a marriage penalty in the payroll tax. Now think of the negative comments you get from a marriage penalty from grassroots America. So here we have a proposal that creates such a marriage penalty in the payroll tax. In other words, some married couples will be paying higher payroll taxes due solely to the fact that they are married. A tax on marriage? This is a direct result of this addition to the second tax rate.

Here is another matter that boggles the mind. The second tax rate kicks in if your wages exceed $200,000 if you are single and $250,000 if you are married. These dollar thresholds are not indexed. They are not indexed, so what happens then when you have inflation?

Another tax where the tax base is not indexed is the AMT. That ought to bring back all the horror stories about not indexing something timely when you first pass it. I think every Member of Congress knows that is an annual problem for us. In the late 1990s, commentators called the AMT the tax system's ``ticking timebomb.'' Fortunately, my friend, the chairman, and I started to diffuse this bomb in the 2001 tax legislation. It appears that my friends on the other side of the aisle have created another tax system ticking timebomb problem.

Finally, we have a caboose of this tax increase express. The caboose is the individual mandate penalty tax. It is a tax. It can be called a penalty, but it is a tax. All you have to do is have the IRS collecting it, as it does, and you know it is a tax. President Obama does not want to acknowledge that the penalty for failing to maintain a government- approved health insurance program is a tax, but it is right here in black and white. The Reid bill amends the Tax Code by adding a new excise tax. It is payable by those Americans who do not purchase government-approved health insurance.

I ask unanimous consent to place section 1501 of the Reid amendment in the Record, which adds this new excise tax to our tax laws.

The kicker here is that CBO has told Congress that roughly one-half of those Americans who will pay this tax are individuals between 100 and 300 percent of poverty. These folks earn less than $250,000 a year. I see the light at the end of the tunnel that this tax increase express is going through. Unfortunately, that light at the end of the tunnel is the tax increase express.

We can derail the tax increase express if we want to.

That is why today I am supporting Senator Crapo's motion to commit the Reid amendment to the Senate Finance Committee. Senator Crapo's motion would require the Finance Committee report a bill back to the Senate that does not include tax increases, fees, and penalties included in the Reid bill.

Why should my Democratic friends vote in favor of the motion? Because they shouldn't want to bear the fallout of legislation that was rushed through Congress as the economic stimulus package was back in February. They shouldn't want to tell their constituents they voted in favor of a bill that increased their premiums. They shouldn't want to vote for a bill that raises taxes on many, only to provide benefit for a few. They shouldn't want to break President Obama's pledge not to tax people making less than $250,000 a year.

What my friends should want is real health care reform, the kind of reform that has broad bipartisan support. I have consistently said that if Congress wants to restructure one-sixth of the economy, it ought to be done on a bipartisan basis, and that is not one or two Republicans voting with Democrats. That is not happening around here on a bipartisan basis. We are debating this 2,074-page bill, a partisan product, a bill that was cobbled together by the Democratic leadership, a bill that has not received approval of the Senate Finance Committee.

I ask my Democratic friends to stop this process foul right now. Vote in favor of Senator Crapo's motion so we can do health care reform in the right way: on a bipartisan basis, in a transparent and open way, so that the American public can understand what we are doing; so the American public can be a part of the process; so that we can find a way to reform our health care system without burdening our constituents with these higher taxes, fees, and penalties.

Let's reduce the out-of-control spending in the Reid amendment and find savings within the health care system. Let's derail the tax increase express before it steamrolls over hard-working Americans and discourages employment, particularly employment in small business, where 70 percent of the new jobs are created. The taxes, fees, and penalties don't need to be the fuel of this locomotive fire.

I ask all of my colleagues to support Senator Crapo's motion to commit the Reid bill to the Finance Committee.

I yield the floor.

Mr. President, yesterday I offered legislation to make permanent a number of education-related tax relief measures. My legislation, S. 2851, also improves and makes permanent helpful provisions for 529 plans and the American opportunity tax credit for education.

At the first hearing I held when I became chairman of the Finance Committee in 2001, I made clear that education tax policy was a priority of mine. As chairman, I was able to remove the 60-payment limit for deducting student loan interest and I was able to increase the income limits for that deduction. This was not the only time I fought hard to allow students to deduct their student loan interest. In 1997 I was able to reinstate the student loan interest deduction that Congress had eliminated from our tax laws. However, the 60-payment limit on the deductibility of student loan interest remained. I ensured that the 2001 tax relief bill took care of that problem. Other incentives for education that I was able to enact into law in 2001 included raising the amount that can be contributed to an education saving account from $500 to $2,000; making distributions from prepaid college savings plans and tuition plans tax-free; and making permanent the tax-free treatment of employer-provided educational assistance. These tax policies and many others, including those for school renovations, repairs and construction, have proven their value to Iowa students in dollars and cents, year after year. The tax relief has delivered measureable educational assistance to Iowans and students and families nationwide, making education more affordable and accessible.

One drawback of enacting these provisions in the 2001 tax relief bill, however, is that there was a sunset provision attached to that entire piece of legislation. All of the tax relief needs to be made permanent. Especially the education-related tax provisions. And that is what my bill today does. My bill makes these provisions permanent.

It is no coincidence that I introduced my education tax bill on the day the President of the United States talked about jobs. Our economy demands well-educated workers. The popularity of education tax incentives is good news for workers who find themselves unemployed or who want to go back to school to advance, or even change,

their careers. Congress is willing to consider permanent tax relief for companies to buy machinery. Why isn't Congress willing to make an investment in people? That's what tax relief for education is. An investment in our future. It is just as important as job-creating tax incentives for businesses. Some will say we can't afford this, but we really can't afford to lose billions of dollars of help for Americans working hard to educate their kids.

Education has made this country great. We should not let this opportunity pass us by. We should not let these education-related tax provisions expire. We should also continue to help make education affordable for families and students. This makes education accessible for all. I look forward to working with my colleagues on passing this bill.

Mr. President, I yield 10 minutes to the Senator from Kansas.

I yield such time as is remaining to the Senator from Utah.

Madam President, before the Senator from North Dakota leaves and before I speak on another issue, I wish to tell him I am going to speak in support of his amendment. But I would like to ask him a question now, if he will answer it for me--a friendly question, but it is something I don't know absolutely for sure, but I believe that pharmaceuticals are about the only thing a consumer in the United States cannot buy anywhere in the world that they want to buy. We ought to give them that same right we do on everything else. There may be some other items I am not aware of, but I think it is only pharmaceuticals that you cannot import from wherever you want to buy them.

I thank the Senator from North Dakota.

I would like to talk about a recent news----

I ask unanimous consent to speak now, if I may.

Fifteen minutes.

I will let the Senators speak, and I will speak tomorrow because I have to go to a meeting. I will let the unanimous consent agreement stand.

I cannot keep it to 10 minutes, and I cannot shorten it. So I will let the unanimous consent agreement stand.

Mr. President, if the Senator is asking me that question, I will tell him that he is absolutely right, not based upon what I say or what the Senator says, but every spring the trustees of Social Security and Medicare look ahead 75 years and they predict what the income and the outlays are going to be based upon the population and the projected growth of the economy and all that stuff. Right now, they are projecting $37 trillion of shortfall over that 75-year period of time. They already told us, and it has materialized, that in the year 2008 we started paying more money out of Medicare than was coming into Medicare, and by the year 2017, as the Senator correctly stated, the trust fund will be out of reserves.

In Medicare.

Mr. President, I had a chance to hear a great deal of what the Senator from Alabama said. I think I would highlight that what he said is what he is hearing from the grassroots of his State, which is very much what I hear from the grassroots of my State: people are very concerned about this piece of legislation leading to the nationalization of health care, similar to what they have seen this administration previously do this year with the nationalization of General Motors, partial nationalization of the financial system--a big deficit. And then they see the money being spent on this bill--$2.5 trillion after it gets fully implemented. And where are you going to get money? And what is that going to do to the economy? And, more importantly, what sort of a legacy is that leaving to our children and grandchildren?

He also correctly stated that I do visit every county every year. The number of counties the Senator had was just a little bit high. We only have 99 counties. But for the 29 years I have been in the U.S. Senate, I have held a town meeting in each one of our counties every year. So I do have the benefit of 2,871 town meetings as a basis for suggesting what people tell me face to face, besides the large number of phone calls we get.

You cannot believe the number of phone calls that are coming in now, the number of e-mails we are getting--historically high. I have never had that before on any issue. I assume it is the same for the State of Alabama, contacting their two Senators as well.

Mr. President, I rise to bring up an issue that is a relatively new issue in this debate, as in the secrecy of the negotiations that are going on around Capitol Hill on the issue of health care reform. These secret negotiations actually started about October 2 when Senator Reid, the leader, had to merge the bill out of the Senate Finance Committee and the bill out of the Senate HELP Committee into one bill. It took a long period of time to do that.

We are in the second week of debate. I hope people realize that 99 Senators ought to have the same privilege that 1 Senator had of getting a grasp of this huge 2,074-page bill. There are still negotiations going on because the leader still does not have locked down the 60 votes that it is going to take to get to finality.

So some of these discussions are: what can we do to get a few votes if we do not have a so-called public option? And the latest of that is: Well, allow people to buy into Medicare. So I want to speak about that issue because it sounds pretty simple. It may get 4 more votes and may get 60 votes, but it is bad. It may be good politically, but it is bad for Medicare and particularly for Medicare in rural areas where we have a difficult time keeping hospitals open, and we have a difficult time recruiting doctors in rural America.

So I would talk about the recent news reports of a proposal being concocted behind closed doors to allow 55- to 64-year-olds to buy into the Medicare Program. Supposedly, this idea has been put on the table to get the votes for supporters of having a brandnew government-run health plan and the people who do not like that.

Back in the spring, such a proposal came up during the early stages of our Finance Committee's health care reform efforts. The idea was originally proposed by President Clinton even going back to 1998. I opposed such a proposal back then, and I oppose such a proposal now. I oppose the proposal because of its negative effect on the Medicare Program and our senior citizens who use Medicare.

The best way to describe the effect of this proposal on the Medicare Program and its beneficiaries is to quote former Senator Phil Gramm of Texas when he was asked about President Clinton's proposal when President Clinton put that proposal on the table back in 1998. Senator Gramm said this about President Clinton's proposal, which would be applicable today as our colleagues are studying it:

If your mother is on the Titanic, and the Titanic is

sinking, the last thing on Earth you want to be preoccupied

with is getting more passengers on the Titanic.

Since its inception in 1965, the Medicare Program has helped ensure senior

access to health care. But, as the Senator from Alabama and I were just discussing, the problems with health care and Medicare are such that Medicare is already under extreme financial pressure. So why would you load more people into a system that Senator Gramm of Texas was referring to as the Titanic? You would not load more people on it as it was going to sink.

This is not to say that this entitlement program, Medicare, is not in need of improvement, but having the 36 million Americans who are age 55 to 64 buy into the program is not an improvement. Even groups supporting the Reid bill, such as the AARP, are pointing out the severe shortcomings of such an approach.

Last summer, the AARP Public Policy Institute published an analysis of the Medicare buy-in concept. In their report, the AARP points out the potential for increased Federal entitlement spending. AARP said:

Expanding the program to more people could raise federal

spending even further if their care is made affordable

through subsidies that would be funded by the existing

Medicare trust funds.

And do not forget the effects of adverse selection from a Medicare buy-in program. Here AARP has studied it, and this is what they say about that:

. . . the premium may be too uncompetitive for those who

don't use much health care and unaffordable for those with

modest incomes. This may limit buy-in enrollment and drive up

cost further.

So this means that this buy-in proposal is likely unsustainable. And we all know what happens when the government creates an unsustainable new program. What happens? The taxpayers end up on the hook for bailing it out down the road sometime.

We all know the Medicare Program has $37 trillion in unfunded obligations. We all know about the pending insolvency of the Medicare Program. The trustees say so every spring.

The Medicare hospital insurance trust fund started going broke last year. In 2008, the Medicare Program began spending more out of this trust fund than was coming in through the payroll tax. The Medicare trustees have been warning all of us for years that this trust fund is going broke. They now predict that it will go broke right around the corner in 2017. Well, as the AARP has pointed out, adding millions to the Medicare Program would almost certainly make things much, much worse for the fiscal health of a program that is not in very good financial shape. This proposal would also make things worse for the 45 million Medicare beneficiaries who paid into the program over the years and are receiving benefits under the program.

Since we started debate on this 2,074-page bill, Members on this side of the aisle have questioned the wisdom of slashing Medicare by $\1/2\ trillion and then using the savings to start a new Federal entitlement program. We on this side have stressed that provider cuts of this magnitude will make it financially harder for providers to care for beneficiaries. We have pointed out that this will worsen beneficiary access to health care, as providers stop treating Medicare patients.

Adding millions more Americans to Medicare on top of the $\1/2\ trillion in Medicare cuts in this Reid bill would make beneficiaries' access to care much worse. But do not take my word for it. Even national hospital associations such as the American Hospital Association and the Federation of American Hospitals are opposing this proposal. They are mobilizing their ranks against this proposal even as I speak. Yes, the same groups that agreed already--and this was back in June--to $155 billion in Medicare cuts--and they did that in an agreement with the White House and got sweetheart deals in this bill-- do not want the Senate to go the route of expanding Medicare for people under 65 years of age. The American Medical Association has also opposed this proposal. These groups recognize the potential for financial disaster by boosting the number of patients with coverage that pays well below cost.

This Medicare buy-in proposal would also jeopardize retiree benefits. Going back to the same AARP analysis that I have quoted, they concluded that a Medicare buy-in program could further reduce employer-sponsored health benefits.

According to the AARP:

. . . a buy-in program might displace retiree coverage now

available through [their] employers.

Still quoting AARP, they said:

As health care costs tend to rise with age, employers might

have the incentive to find ways to avoid offering private

coverage for early retirees. . . .

So with fewer patients with higher paying private coverage, there is less opportunity for providers to cost-shift to make up for low Medicare payments, because everybody recognizes the Federal Government does not pay 100 percent of costs. This would make it even harder for providers to treat Medicare beneficiaries, and as a result, beneficiaries would have an even harder time finding a provider to treat them.

I come from a rural State where Medicare reimbursement is already lower than almost every other State in the Nation, so I have serious concerns about the ability of the Iowa providers to keep their doors open if more and more of their reimbursement is coming from Medicare. I know this is a concern that is shared by rural State Members of this body from both sides of the aisle. But losing providers to serve Medicare beneficiaries would only be the beginning of access problems caused by a Medicare buy-in program. Because if you think it would be tough to keep existing Medicare providers, think how hard it would be then to recruit new ones.

Provider recruitment is already a major problem in rural States, particularly my State of Iowa. This issue comes up during my meetings with constituents in Washington or during the townhall meetings I hold in each of Iowa's 99 counties every year. It is already a challenge under the current Medicare Program for Iowa to compete for providers with urban areas where Medicare reimbursement is higher.

I hear countless stories from constituents where they make great efforts to recruit doctors only to lose them to areas where Medicare reimbursement is higher. The Medicare buy-in will only make this situation worse in my State of Iowa, because more and more reimbursement would come from Medicare. So the current and future Medicare beneficiaries would be assured of limited access to providers because of this buy-in.

AARP pointed out another flaw in this buy-in proposal. In their analysis, AARP warned that there are large cost-sharing requirements in Medicare, so buy-in enrollees would still be exposed to significant cost sharing. Maybe these buy-in enrollees would have the resources to purchase supplemental Medicare policies to defray these cost-sharing requirements. Perhaps AARP is thinking of making even more money by selling supplemental policies to these retirees.

I share the goal of getting more Americans covered, but expanding the Medicare Program to early retirees is not the answer. Medicare beneficiaries have paid in to this program all these years and rightfully have the expectation to receive the benefits to which they are entitled under the program. The Medicare buy-in proposal would jeopardize these benefits. It would jeopardize existing retiree benefits. It would leave retirees exposed to significant cost sharing. It would be unsustainable and taxpayers would end up footing the bill.

I yield the floor.

Mr. President, today I am offering legislation to make permanent a number of education-related tax relief measures. My legislation also improves and makes permanent helpful provisions for 529 plans and the American Opportunity tax credit for education.

At the first hearing I held when I became Chairman of the Finance Committee in 2001, I made clear that education tax policy was a priority of mine. As Chairman, I was able to remove the 60-payment limit for deducting student loan interest and I was able to increase the income limits for that deduction. This was not the only time I fought hard to allow students to deduct their student loan interest. In 1997, I was able to re-instate the student loan interest deduction that Congress had eliminated from our tax laws. However, the 60-payment limit on the deductibility of student loan interest remained. I ensured that the 2001 tax relief bill took care of that problem. Other incentives for education that I was able to enact into law in 2001 included raising the amount that can be contributed to an education saving account from $500 to $2,000; making distributions from pre-paid college savings plans and tuition plans tax-free; and making permanent the tax-free treatment of employer-provided educational assistance. These tax policies and many others, including those for school renovations, repairs and construction, have proven their value to Iowa students in dollars and cents, year after year. The tax relief has delivered measureable educational assistance to Iowans and students and families nationwide, making education more affordable and accessible.

One draw-back of enacting these provisions in the 2001 tax relief bill, however, is that there was a sunset provision attached to that entire piece of legislation. All of the tax relief needs to be made permanent. Especially the education-related tax provisions. That is what my bill today does. My bill makes these provisions permanent.

It is no coincidence that I am introducing my education tax bill on the day the President of the United States talked about jobs. Our economy demands well-educated workers. The popularity of education tax incentives is good news for workers who find themselves unemployed or who want to go back to school to advance, or even change, their careers. Congress is willing to consider permanent tax relief for companies to buy machinery. Why isn't Congress willing to make an investment in people? That is what tax relief for education is. An investment in our future. It is just as important as job-creating tax incentives for businesses. Some will say we can't afford this, but we really can't afford to lose billions of dollars of help for Americans working hard to educate their kids.

Education has made this country great. We should not let this opportunity pass us by. We should not let these education-related tax provisions expire. We should also continue to help make education affordable for families and students. This makes education accessible for all. I look forward to working with my colleagues on passing this bill.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, opponents of the Gregg amendment claim the Reid bill doesn't technically change the law on guaranteed benefits for beneficiaries. But they are ignoring the fact that while those benefits may be ``technically guaranteed,'' if the cuts put health care providers out of business, then those guarantees will be nothing more than useless words in the Medicare Act. Guaranteed benefits are not worth much without health care providers that can treat patients, provide home health services, and run hospitals and hospice agencies. These claims are not good enough to assure seniors who have paid into the Medicare Program for all these years. It is not good enough for protecting access to health care services and the benefits that our seniors have been promised.

My colleague from New Hampshire in his amendment would back up those claims with very real enforceable mechanisms to ensure that Medicare savings are not being used to fund a whole new program at a time when the trust fund is just about broke. The Gregg amendment is needed to protect the Medicare Program. After all, if you knew the Medicare Program already had $37 trillion in unfunded obligations, would you be assured without an enforcement mechanism to back up those promises? No guarantee is worth the paper it is written on without an enforcement mechanism to back it up. That is what the Gregg amendment is all about; otherwise, it is just a meaningless guarantee that our friends on the other side of the aisle are talking about. It is not real without an enforcement mechanism.

Let me say for a third time, the Gregg amendment provides that enforcement mechanism. It makes guarantees real. It then goes much further than just the words we get from the other side of the aisle to make sure that what seniors have they will actually get when needed.

Opposition to the Gregg amendment shines light on this issue. If the Gregg amendment is not approved, it should be clear to everyone watching that all the guarantees that are made from the other side of the aisle that Medicare is protected in the Reid bill are worthless. As a result, I hope everyone will be watching carefully how the other side votes on the Gregg amendment. The Gregg amendment is essential for protecting the Medicare Program. It is essential for making guarantees real.

The way the Gregg amendment works to enforce those guarantees is quite simple. The Gregg amendment would make sure the Medicare Program is not used as a piggy bank to spend for other purposes. It would make sure the Medicare Program is not being raided to fund this new program, as the other side claims. Under this important amendment, the Director of the White House Office of Management and Budget and Medicare's Chief Actuary would both be required to add up non-Medicare savings in the bill and compare that total to the total of new spending and revenues in this bill. The Gregg amendment works then that if the non-Medicare savings don't offset all the new costs, then the Treasury Secretary and the Health and Human Services Secretary would be prohibited from implementing the new spending or revenue provisions in the bill. By doing so, the Gregg amendment would ensure that non-Medicare savings are, in fact, paying for the new spending in this bill. It would ensure at the same time that Medicare itself is not being used to pay for new spending in the bill.

It is very simple, very straightforward. It brings common sense to this whole argument that has been full of a lot of nonsense before now. The amendment, therefore, would prevent massive government expansion at the expense of Medicare beneficiaries. Massive expansion of government is one thing, if it is paid for, but it is quite another thing if you take the money out of a trust fund that is on its way to being broke and use it to set up a brandnew entitlement program to the tune of $464 billion.

As opposed to the mere nonbinding sense-of-the-Senate resolution the other side has offered to pretend to protect Medicare, this Gregg amendment requires action, action that has to be taken to protect the Medicare Program. The Gregg amendment is the enforcement mechanism for the guarantees the other side says they are making to protect Medicare. Slashing Medicare payments to start up another new and, in fact, unsustainable government entitlement program is not the way to address big and unsustainable budgets.

Amendment No. 2939

I would like to take a little bit of time to discuss the Pryor amendment. I have always been a strong supporter of transparency. In order to have a successful free market, consumers need to have information. I can't think of any reason, besides my strong objection to the underlying 2,074-page bill, to oppose the Pryor amendment. It is pretty straightforward. It requires that the Secretary of Health and Human Services have a rating system for private health plans. That sounds OK to me. An informed consumer makes better decisions. So I don't object to the Pryor amendment. But I do object to the fact that the Pryor amendment is more proof that this bill is not being crafted out in the open on the Senate floor.

The Associated Press has confirmed, based on an e-mail circulated by Democratic staff, that the Bennet amendment of last week to protect Medicare was simply ``a message amendment.''

The New York Times went on to call the Bennet amendment ``meaningless.'' Now we have a Pryor amendment that requires a level of transparency that, in fact, is already required by the bill. If you look at page 134, the bill already describes a rating system developed by the Secretary that consumers can use to choose the right health insurance plan. So if the underlying bill is already doing this, I can only assume this amendment by my friend from Arkansas is specifically designed to buy time so the White House and Democratic leadership can cut deals and twist arms behind closed doors.

That is right. The American people need to know this bill is not being written on the Senate floor. In fact, we have a 2,074-page bill before us that took since October 2, until we took it up, for one Senator, the majority leader, to put together. Somehow the other 99 Senators shouldn't have 3 weeks to look at a bill that took well over a month to put together.

Then we had the President here yesterday speaking to his caucus. That kind of obviates any efforts to get bipartisan support for this bill. I think it gives further proof that it is not only partisan but that what this final 2,074-page bill is, we don't know yet. They are trying to put together some sort of a group that can get 60 votes to get a bill passed.

Do we really know what sort of a Christmas present we are giving to the American people with this health reform bill? I don't think so.

I yield the floor.

Madam President, for the benefit of my colleagues waiting to speak, I don't think I will speak much more than 10 minutes. Before I speak on my purpose for coming to the floor to support Senator McCain's amendment, I want to take a couple of minutes to go over a source of information that is no longer credible, which has been used in debate on the floor several times, used throughout the year-- information that has been in letters to the editor of Iowa newspapers.

The most recent hearing of this was when the Senator from California rose to talk about the quality of our health care and the reference to the fact that the United States is 37th out of all of the nations of the world in quality of health care.

I don't deny we have to do a lot to improve the quality of health care in America. I even admit that in this legislation, though I oppose the bulk of this 2,074-page bill, there is a lot in the bill that has to do with the enhancing of the quality of care.

We keep hearing about the United States being 37th in quality. That comes from a World Health Organization analysis that was made back in the year 2000, ranking the United States among all the other nations. It is a 10-year-old report that was flawed in its analysis at the very outset. Yet it is repeated as if gospel truth by almost anybody who wants to denigrate America's health care system and build a case for this monstrosity of a bill we have before us. When I call it a monstrosity, I will say it has some very good provisions in it that would enhance the quality of care. The World Health Organization no longer produces such a ranking table because of the complexities of the task. The rankings were flawed because they judged health care systems for problems--cultural, behavioral, and economic--that are not controlled by health care. There is no differentiation between the quality of medical systems and other factors, such as diet, exercise, and violent crime rates, which ought to be taken into consideration when considering a nation's delivering quality of health care.

The editor in chief of this 2000 report of the World Health Organization, Philip Musgrove, called the figures `` . . . many made-up numbers,'' and the result a ``nonsense ranking.'' Dr. Musgrove, an economist who is now deputy editor of the journal Health Affairs, said he was hired to edit the report's text but didn't fully understand the methodology until after the report was released. Once he left the World Health Organization, he wrote an article in 2003 for the medical journal Lancet criticizing the rankings as ``meaningless.''

The U.S. health system spends more than any other country per capita and was ranked 37th out of 191 due to that spending alone. Prior to considering how much we spend, the United States was ranked 15th, not 37th.

The Dominican Republic, Costa Rica, and Morocco ranked 42nd, 45th, and 94th before adjusting for spending levels. After the adjustment for spending levels, can you believe it? They ranked above the United States--35th, 36th, and 29th, respectively.

The United States ranked first in responsiveness. That means respect for persons and prompt attention. Americans understand and appreciate this quality care. This will be lost in this massive health care reform bill when the government takes more control.

Experts in the field of health, such as Mark Pearson, head of health for the

Organization of Economic Cooperation and Development, OECD, was quoted as saying:

It's a very notorious ranking. Health analysts don't like

to talk about it in polite company. It's one of those things

that we wish would go away.

I hope my colleagues will take that into consideration when they bring up the rationale for this bill, that it is because of that World Health Organization study, which I think what I said and a lot of other things you can say about it ought to put it into proper perspective.

For my support of the McCain motion to bring equalization among the 50 States for the Medicare Advantage portions of this bill, I have spent the past 28 years in Congress working to make sure that rural Iowans have access to the same quality of health care as people living in more urban areas.

Medicare, since 1965, has been a national program. Well, it is a national program with traditional Medicare. But before we brought equity to Medicare Advantage, it wasn't a national program. It was a program for California, Arizona, Texas, New York, Florida, Chicago, or near the Midwest, maybe Omaha. Since Medicare Advantage was not a national program, and since Medicare since 1965 has been a national program, I set out in the Medicare Modernization Act to bring equity to rural America just as we have in urban America. I fought to make sure that seniors living in rural areas would have the same choices as seniors living in Miami, New York City, or Los Angeles.

That is simply saying that wherever you live in the United States, you have Medicare--traditional Medicare. Before then, wherever you lived in the United States, in most rural areas you didn't have Medicare Advantage. Since Medicare is a national program, people living in rural America ought to have the same choice as those in urban America.

Today that is the case. Seniors in every county in Iowa have a choice between traditional Medicare and Medicare Advantage. That is a big improvement, since prior to the Medicare Modernization Act not all Iowans had that choice. I can narrow it down to 1 out of 99 counties-- Pottawattamie County, across from Omaha, had Medicare Advantage. The other 98 counties didn't have it. I want to tell you, there are still inequities, because Iowa providers offer high-quality care that leads to less utilization. Iowans get approximately $1,500 less per year in Medicare Advantage benefits than seniors living in Florida. Under this bill, Iowans will see even less in Medicare Advantage benefits. It looks like that won't be the case for some lucky Floridians.

In another one of those backroom deals--a backroom deal that seemed to be needed to get 60 votes, backroom deals that are still being attempted to get 60 votes--the Senator from Florida, in one of these backroom deals, was able to secure a provision in the Finance Committee bill that would make sure that seniors in certain Florida counties are able to maintain their current benefits. I am not talking about the so- called guaranteed benefits that Democrats say they are protecting. The provision secured by the Senator from Florida will also protect additional and extra benefits for Floridians. In pushing for this amendment, the senior Senator from Florida said:

It would be intolerable to ask senior citizens to give up

substantial health benefits they are enjoying under Medicare.

I guess Floridians weren't satisfied with the promise that has been made throughout the last 2 weeks of debate on this bill to protect the so-called guaranteed benefits. Seniors in Florida still wanted the lower cost sharing, wellness programs and vision, hearing and dental benefits they have come to rely on. Now we have the Senator from Pennsylvania filing an amendment to help Medicare beneficiaries in Pennsylvania protect their extra benefits, to get these extra benefits that people on Medicare Advantage have.

I am guessing that seniors in Pennsylvania must have also picked up on the Democrats' hollow promises to protect guaranteed benefits but not worry about other benefits. In fact, the presence of these special deals is proof that this bill is cutting Medicare benefits.

It is even proof that some Senators are worried about going back to their constituents and trying to explain the difference between cutting guaranteed and additional benefits, and explaining why they voted to cut Medicare Advantage benefits by 64 percent. Why else would these special deals be necessary?

I am here to ask my colleagues, why should seniors in Florida or Pennsylvania get to keep their extra benefits, while more than 9 million seniors in other parts of the country see an average cut of 64 percent? To quote the Senator from Florida, isn't this also intolerable?

My colleagues on the other side talk about efficiency and fairness, but they are supporting a bill that maintains the highest Medicare Advantage payments in the country, while slashing benefits in higher quality rural areas. One of those higher quality rural areas is the State of Iowa, where we are fifth in quality but near the bottom of 50 States in reimbursement on Medicare, whereas other States are fiftieth in quality and No. 1 in reimbursement on health care.

All of this doesn't sound very efficient or fair to me. Senator McCain's motion is pretty straightforward. It goes State by State. I am not going to read all 50 States, but it says here that 1 million--it is going to benefit the 70,000 Medicare Advantage enrollees in Arkansas. It is going to benefit the 198,000 Medicare Advantage enrollees in Colorado. In Iowa, it is probably something in the neighborhood of 63,902. It will make sure that seniors in every other State in the country--red States and blue States--get the same deal Senator Nelson got for Florida.

A vote for the McCain amendment is simply a vote for equity. But a vote against the amendment is a vote to favor backroom deals that put the interest of a handful of Floridians above 10 million seniors across the country.

I urge my colleagues to support all seniors and vote for the McCain motion.

I yield the floor.

Madam President, there are a number of issues that this amendment raises. Some are health care-related, most are not.

First, this amendment amends section 162(m) of the Tax Code--a tax law intended to curb excessive executive compensation.

Unfortunately, section 162(m) has been a disaster. It has encouraged companies to cook up complex design packages so as to avoid the limitations under the law.

Actually, excessive executive compensation exploded as a direct result of section 162(m)--which was enacted back in 1993.

I have consistently made it clear that the outrageous pay practices of many companies must stop. True pay-for-performance must be the cornerstone of any compensation package. And the boards of directors, compensation committees, and shareholders must all be partners in practicing good corporate governance. We should look to reform section 162(m) of the Tax Code, not add to it. And we should look at whether Congress needs to reform the way corporate governance is practiced.

This amendment adds to section 162(m). It does not reform it. This amendment does nothing to empower shareholders to hold the corporation's board accountable. All it does is hurt shareholders by taking money out of the company and giving it to the government.

That is right. By limiting a corporation's deduction, shareholders are the ones who are disadvantaged, not the corporation.

My friends on the other side of the aisle forget that seniors are often shareholders who rely on dividends and capital gains for income to live on day in and day out. So actually, my Democratic friends are enacting policies that will hurt seniors. All in an effort to show the country that they have it in for the big, bad insurance companies.

I also find it interesting to hear my friends say that it is unfair for insurance companies to get a taxpayer funded ``subsidy'' in the form of a tax deduction.

First, all corporations are allowed to deduct compensation as a business expense. Big, small, private, and public corporations get this same tax deduction.

Are these companies getting a tax subsidy? If so, why not take the subsidy away from them?

Now, my friends on the other side may argue that these restrictions are just like those Congress passed in T-A-R-P. And the way the legislation works, they would be correct.

But, the executive compensation restrictions in T-A-R-P were conditions for receiving taxpayer dollars. My constituents in Iowa would call them bailouts.

Now my friends may argue that health insurance companies are benefiting from their reforms and they should pay their ``fair share.'' They may also say that they are receiving the government-subsidized tax credits for health insurance, which is taxpayer dollars.

The main reason why the government is subsidizing health insurance for low-income individuals is because the Reid bill forces people to buy health insurance.

If you force people to buy insurance, you have to make sure it is affordable for them to buy. This has forced the government to spend close to $400 billion on these tax credits, which is one of most expensive parts of the Reid bill. And the cost of these tax credits are paid with higher taxes, fees, and penalties on the majority of Americans. Paid by many of those who earn less than $250,000 a year.

Data from the Joint Committee on Taxation tells us that 38 percent of tax returns making under $200,000 in 2019 will see a tax increase under the Reid bill. Yet only 8 percent of tax returns in 2019 will be benefiting from the tax credit. That doesn't seem balanced.

Finally, this amendment directs the revenue generated from it to the Medicare trust fund. I commend my Democratic friends for crafting policies that would help shore up Medicare. What is interesting is that this bill cuts Medicare. To the tune of $400 billion--that is billion with a B.

And the money raised from cutting Medicare is not being directed to help shore up Medicare. Rather, the money is being spent on expanding and creating new entitlement programs. The Joint Committee on Taxation scored this amendment as raising $651 million over 10 years--that is million with an M.

So what we have here is $400 billion in cuts in Medicare that is being used for other spending, in exchange for $600 million which would be directed Medicare trust fund. Doesn't seem like a fair trade.

Do my friends on the other side feel guilty for using Medicare money for non-Medicare purposes? And to make up for this guilt, they decided to direct non-Medicare-related money to the Medicare trust fund?

I will close by saying that my Democratic friends will take to the floor and say that anyone who votes against this amendment is ``in the pockets of the insurance companies.'' I will first tell my friends that they should look in the mirror. Then I will say opposing irrational policies that add complexity to our tax laws is not protecting insurance companies.

Let's get on to reforming our health care system, instead of voting on amendments so my Democratic friends can (1) look like they are taking it to the insurance companies, and so they can look like (2) they are helping Medicare solvency.

Mr. President, I rise to speak in favor of the amendment of the Senator from New Hampshire.

Because as I have been saying, the people who wrote the excesses of the Reid bill appear willfully ignorant of what is going on in the rest of the economy outside of health care.

We are a nation facing very challenging economic times with industries in financial crisis and Federal debt increasing to all-time highs.

So we should be considering a bill that would create jobs and prevent this country from being burdened with a bigger and more unsustainable Federal budget instead of this health bill.

But instead, we are now considering a bill that cuts half a trillion dollars from the Medicare Program to fund yet another unsustainable health care entitlement program.

You have heard from Members on this side of the aisle about how flawed this approach is and how these drastic Medicare cuts will threaten beneficiary access to care.

Medicare's chief actuary at the U.S. Department of Health and Human Services has warned Congress in his report that these cuts could jeopardize access to health care for beneficiaries.

In fact, a number of Members on the other side of the aisle have made clear that they share our concerns when they joined us to vote in favor of motions to eliminate these cuts.

Most of the Members on the other side of the aisle, however, claim that this bill does no such thing.

They claim that Medicare money is not being used to start up yet another unsustainable entitlement program that we clearly can't afford.

They claim that the Reid bill doesn't technically change the law on guaranteed benefits for beneficiaries.

They are ignoring the fact that while those benefits may be technically guaranteed, if the cuts put health care providers out of business, then those guarantees will be nothing more than useless words in the Medicare Act.

Guaranteed benefits are not worth much without health care providers who can treat patients, provide home health services, run the hospitals and hospice agencies.

These claims are not good enough to assure seniors who have paid into the Medicare Program all these years. It is not good enough for protecting access to the health care services and benefits they were promised.

So the Gregg amendment would back up those claims with a real enforceable mechanism to ensure that Medicare savings aren't being used to fund a new program.

The Gregg amendment is needed to protect the Medicare Program.

After all, if you knew that the Medicare Program already had $37 trillion in unfunded obligations, would you be assured without an enforcement mechanism to back up those promises?

No guarantee is worth the paper it is written on without an enforcement mechanism to back it up. Otherwise, it is just a meaningless guarantee. It is not real without an enforcement mechanism.

The Gregg amendment provides that enforcement mechanism. It makes the guarantee real.

Opposition to the Gregg amendment will shine a light on the issue. If the Gregg amendment is not approved, it should be clear to everyone watching that all the guarantees they are making that Medicare is protected in the Reid bill are, in fact, worthless. As a result, I hope that everyone will be watching carefully how the other side votes on the Gregg amendment.

Now supporters of the Reid bill trumpet the fact that their drastic and permanent Medicare cuts extend the life of the program.

I agree that we can't ignore the pending insolvency of the Medicare Program.

The Medicare hospital insurance trust fund started going broke last year. In 2008, the Medicare Program began spending more out of this trust fund than it is taking in.

The Medicare trustees have been warning all of us for years that the trust fund is going broke. They now predict that it will go broke right around the corner in 2017.

But rather than work to bridge Medicare's $37 trillion in unfunded liabilities, this bill cuts half a trillion dollars from the Medicare Program to fund yet another unsustainable health care entitlement program.

By diverting Medicare resources elsewhere, this bill ignores other major problems in the Medicare Program, like fixing the physician payment flaw with the sustainable growth rate formula, or SGR as it is known.

So the few years of extended life this bill would give to the Medicare hospital insurance trust fund is a Pyrrhic victory.

Because the drastic and permanent Medicare cuts in this bill will worsen health care access and quality.

And the Reid bill leaves problems that have long been vexing Congress like the fatally flawed physician payment formula unsolved.

The Reid bill will leave Congress with few options for fixing these problems.

So the Gregg amendment is essential for protecting the Medicare Program. It is essential for making those guarantees real.

The way the Gregg amendment works to enforce those guarantees is quite simple.

The Gregg amendment would make sure that the Medicare Program is not used as a piggy bank to spend for other purposes. It would make sure that the Medicare Program is not being raided to fund this new program as the other side claims.

Under this important amendment, the director of the White House Office of Management and Budget and Medicare's chief actuary would both be required to add up non-Medicare savings in the bill and compare that total to the total of new spending and revenues in the bill.

If non-Medicare savings don't offset all the new costs, then the Treasury Secretary and the HHS Secretary would be prohibited from implementing the new spending or revenue provisions in the bill.

By doing so, the Gregg amendment would ensure that the non-Medicare savings are paying for the new spending in this bill. And it would ensure that Medicare itself is not being used to pay for the new spending in the bill.

It is that simple.

The amendment therefore would prevent massive government expansions at the expense of Medicare beneficiaries.

As you can see, this amendment has teeth. This amendment is real.

As opposed to a mere nonbinding sense of the Senate resolution that the other side has offered to pretend to protect Medicare, the Gregg amendment requires action to protect the Medicare Program.

The Gregg amendment is the enforcement mechanism for the guarantees the other side says they are making to protect Medicare benefits.

Slashing Medicare payments to start up another new unsustainable government entitlement program is not the way to address a big and unsustainable budget.

That is why I support the Gregg amendment. And I urge my colleagues to do the same.

Vote to protect Medicare.

Vote to keep Medicare from being used to fund a separate new program.

Vote to keep Medicare funds from being siphoned off.

Vote to put in place a real guarantee that Medicare funds won't be used.

Vote to back up those promises with real action.

I yield the floor.

Mr. President, I had a chance to hear the Senator from North Dakota. I am not rising to speak on that issue right now, but I support him in that effort. I thank him for working with my staff over a period of years to develop a bill that does not violate any of our trade agreements. That is an important aspect of the work of the Senate Finance Committee on which I serve. I look forward to that debate coming up.

I yield.

I thank Senator Dorgan. He gave a very good description just now of how careful this piece of legislation--of which I am a cosponsor--would go not only to make price transparency and price competitiveness much better for the American consumer but to guarantee the same safety we would for drugs imported as we do for drugs produced here.

I rise to speak in a generic way about this 2,074-page bill that is before us, to speak about people who have raised questions about whether this bill is or is not a first step toward a government takeover of health care. I take the position that it is definitely a first step in that direction. If you spend a little bit of time watching any of the cable news stations, you will hear someone talking about how the current health reform proposals represent a government takeover of our health care system. The phrase ``government takeover'' has become a common talking point for people opposed to this pending bill. Unfortunately, these opponents rarely explain why this bill warrants such a claim, that it is a step toward government takeover of the entire health care system or the nationalization of health care. Supporters of these bills don't do much better as well. These supporters dispute the claim but at the same time they seem unaware of all the new roles and responsibilities the Federal Government is taking on in this 2,074-page health care reform bill. I want to explain why I see the pending bills as a government takeover of our health care system.

I don't come to the floor to scare people or misinform them. I am more than willing to listen to different points of view. But if I am going to use the phrase ``government takeover,'' I want to make sure other Senators--and particularly my constituents in Iowa--know what I am talking about. I wish to start with the simplest example of government takeover, the government-run plan. It is sometimes referred to as the public option. This one seems to be pretty straightforward. In other words, the government-run plan is a pretty straightforward example that people can understand the government getting more involved.

If you wonder maybe sometimes why the public at the grassroots is a little bit concerned about the takeover of health care by the Federal Government, remember that it was only a few months ago the Federal Government nationalized General Motors, as an example, and has partially nationalized individual banks and financial institutions--in a sense, taking a big step toward nationalizing the whole financial system with the Federal Reserve system's intimate involvement and the Secretary of the Treasury's intimate involvement in a lot of decision making there or decisions that affect the entire financial system.

We are here with the prospect of building upon other things that have happened this year, having the Federal Government take over health care. The public option is one step in that direction. I see a government-run plan, whether it is an opt out, an opt in, a trigger or a straight government plan paying Medicare rates, as this country's first step toward a single-payer system. A single-payer system is a government-run system, one system for the entire country, as in Canada, without options or choices that people have. I don't want you to take my word for it.

Let's look at a quote from Representative Jan Schakowsky of Illinois:

A public option will put the private insurance industry out

of business and lead to single payer.

I have another quote by Representative Barney Frank of Massachusetts:

If we could get a good public option it could lead to

single payer, and that's the best way to reach single payer.

Judging by these quotes, I would say both of these prominent Members of the Democratic party agree that the so-called public option is a first step toward government taking over our health care system. But we don't need to rely only upon sound bites. Let me explain why I see the government-run plan leading to a single-payer system. The government- run plan may start out with some rules to keep it from having an unfair advantage over private insurers. Supporters might say it is on a level playing field with private insurers. They may say it would have to pay the same rates, form networks, and be independently solvent. But I remind people, when they hear those promises today, why something the government is doing can be competitive and not unfair competition with the private sector.

Those same kinds of promises were made during the Medicare debate way back in 1965. Supporters of the bill in 1965 promised the new government health insurance program would not interfere with the practice of medicine and would pay fair reimbursement rates. But over time, as the costs of the program exceeded projections, the government broke promises it made. The pending bills represent a government takeover of our health care system, because I believe the same thing that happened in 1965 with Medicare, the government breaking its promises, will also happen with the so-called public option.

In fact, I want to quote from a recent Wall Street Journal article:

Any policy guardrails built this year can be dismantled

once the basic public option architecture is in place . . .

That is what has always happened with government health

programs.

Isn't that what Representative Schakowsky and Representative Frank were saying? Start in a very simple way, saying to people the private sector needs competition. Government will give that competition. But start with a government-run plan so you can end up with a single-payer system, regardless of how innocent it sounded when you first started out. Slowly but surely, the government plan would take over the market. This is just one example of why I see the pending bills as a government takeover of our health care system. But there are others.

I wish to take a look at some health insurance reforms that are within this bill. All of these insurance reforms aren't bad as separate items. But coupled with all the bad things in the bill, it makes it difficult to sort out the good things.

For instance, I support stronger rules and regulations for private insurers. This is within the principle of the Federal Government's constitutional power to regulate interstate commerce, going way back to 1944 or 1945. The Supreme Court ruled that. Then Congress passed the McCarran-Ferguson Act and gave it right back to the States to do, where it has been basically regulated. But this bill brings a lot of that regulation back to the Federal Government. I do support some stronger rules and regulations. Congress should make sure that people are not discriminated against because of preexisting conditions, and people should not have to stay up at night worrying about whether their insurance will be there when they get sick and need it most, just as you wouldn't want your fire insurance on your house canceled at the same time the fire starts in the house.

Those are the kinds of reforms I say are good in this bill and could get strong bipartisan support. But the pending bills go much further than creating stronger rules and regulations.

First, let's keep in mind that under current law, health insurance is primarily regulated under McCarran-Ferguson at the State level. State insurance commissioners and legislatures set most of the rules. The health reform proposals being debated in the Senate and over in the House would have the Federal Government take over these responsibilities. Under the present bills, the Federal Government, either through the Secretary of Health and Human Services, or a newly created office of health choices commissioner, or an unelected Federal health board is going to decide what health insurance has to look like. What every health plan has to cover is what the Federal Government is going to decide.

It is not just a case of ending discrimination. It is a case of the Federal Government saying what that health insurance plan needs to look like. If your current coverage does not meet one of the bronze, silver, gold, or platinum categories set up by the Federal Government--despite the President's promise--you may not be able to keep what you have.

The Federal Government is also going to set a national standard for how much insurers can vary prices between younger and older beneficiaries. These reforms will result in drastic price increases, particularly for younger and healthier beneficiaries. This means millions of people who are expecting lower costs as a result of reform will end up paying higher premiums.

So the Federal Government will decide how much plans can charge and what benefits can be covered. To help make these decisions, the Federal Government will have a newly created comparative effectiveness research program. This program would be similar to the ones in Great Britain and other foreign governments that decide which treatments you can and cannot have.

I want everyone to understand that the principle of comparative effectiveness research in and of itself is not something I oppose because I think when it is used as a way of informing patients and providers about best practices, it is a good thing to have. But I am also worried this research could be used as a tool for government to ration care. Especially the reason for my concern is the recently passed House bill failed to include a prohibition on rationing that was in their original discussion draft. That discussion draft of the House bill, H.R. 3200, stated that the committee should ``[e]nsure that essential benefits coverage does not lead to rationing of health care.''

But, unfortunately, that line was not included in the final bill.

Now, that makes you wonder: When everybody says comparative effectiveness research is not going to be used to ration care, then why would you object to a statement saying: ``Ensure that essential benefits coverage does not lead to rationing of health care.'' Why wouldn't that be in the bill if that is what you believe?

So under these pending bills, you have the Federal Government telling private plans how much they can charge and deciding what benefits they have to cover. Then the Federal Government is going to tell them-- again, a Federal intervention in health care and a step toward more nationalization--they are not only going to tell them what benefits they have to cover, but then the Federal Government is going to tell you that you have to buy it.

Understand, as far as I know, in the 225-year history of our great country, the Federal Government has never said you had to buy anything--buy or not buy anything. They do not tell you.

Somebody is going to say: Well, the States make you buy car insurance. Well, under the 10th amendment, the States can do anything they want to that is not prohibited by the Federal Government. But the Federal Government is a government of limited power.

So you have the Federal Government saying you have to buy health insurance. But the government takeover does not stop there. The proposed bills also include the biggest expansion of the Medicaid Program since it was created in 1965. The bills force 14 million more Americans into Medicaid, even though many doctors will not see Medicaid patients. Under current law, the government already pays for about 50 percent of health care. But with the new subsidies and massive Medicaid expansion, the Federal Government will eclipse the private market when it comes to paying for health care services.

I am sure some of my colleagues saw recently released data from the inspector general showing that about 12 percent of Medicare payments were payment errors that could be the result of fraud, waste, and abuse. It is no wonder then that Medicare is scheduled to be insolvent within the next 10 years.

Clearly, the government cannot afford or even manage the programs it

has now. But here we are debating the single largest expansion of government health care in history embodied in this 2,074-page bill.

So I would like to review why I see the current bill as a government takeover of our health care system.

First, there is a government-run plan that will drive private health plans out of business. In fact, some Democratic legislators have said publicly they see it as a first step toward a single-payer system.

Second, States will no longer be in charge of their own insurance markets. The Federal Government is going to take over the responsibility of setting premiums and defining benefits. So regardless of whether you are getting your health insurance through an employer or on your own, when you go to buy a new policy, the Federal Government is going to tell you what you can and cannot buy. If you do not buy the coverage the government has chosen for you, you could end up paying a new tax or even end up in jail under this new intrusive health insurance mandate that is going to be enforced by the Internal Revenue Service.

Interestingly, an analysis of similar health reform legislation said the IRS would have to grow by 25 percent in order to manage all the new taxes, fees, and mandates.

By the way, I have written a letter to the Secretary of the Treasury trying to get exactly some estimate of how much money it is going to take for the IRS to administer this program, and we do not have an answer yet.

Finally, we have the single largest expansion of Medicaid since its inception. Current proposals plan to add 14 million people to the Medicaid Program--a program that States already cannot afford.

All of this begs the question then: At more than 2,000 pages, and about $2.5 trillion in spending when fully implemented, how can anyone say the pending bills do not represent a government takeover of health care? From the government-run plan, to a Federal takeover of private health insurance, to a massive expansion of Medicaid, I find it hard to call the pending bills anything else.

The American people want lower costs, higher quality, and better access. That is clear. I share these goals, but I cannot support any bill that I believe hands our private system of medicine over to a bunch of Washington bureaucrats. That is not what my constituents want, and it is not what this country needs.

I yield the floor.

Mr. President, I yield 5 minutes to Senator Coburn.

Mr. President, I yield 5 minutes to the Senator from Georgia.

I yield to Senator Murkowski for 5 minutes.

Madam President, I yield myself 5 minutes.

I rise to tell my colleagues why I am going to vote against the Lincoln executive compensation amendment. This amendment picks out one set of executives in the entire health care arena and singles out that one set of executives for limits on compensation. In the entire health care

sector of the economy, this amendment suggests that only one group of executives warrants this sort of special treatment, and that happens to be the executives of health insurance companies. This amendment then takes that excess compensation that apparently Congress knows is the appropriate amount for compensation and devotes that excess money to the Medicare trust fund.

Well, a very commonsense question in this town of nonsense is, why not limit compensation for executives in other areas of health care? What about the executives of hospitals? Shouldn't their excess compensation go to protect Medicare? Why not executives of nursing homes then? Why not executives of medical device manufacturers? Why not limit compensation on the people who run home health agencies? Why not limit compensation for doctors? Why not limit compensation for executives at the drug companies?

Well, let's wait a second on that one. We know the answer to the one about why not include drug companies. This amendment can't touch drug company executives because their industry cut a secret deal where they agreed to some things in this bill, and they are going to get a huge payoff in profits once this goes into effect, as long as they don't open their big mouth and fight this legislation.

Of course, this all adds up because if you are watching TV at home, or even here on the Hill, big PhRMA is running ads all over the country in support of this 2,074-page Reid bill.

If the idea is for Congress to set the precedent of limiting compensation to protect the Medicare trust fund, then shouldn't we branch out even beyond the health care industry? We could get a lot of compensation--or we could get a lot of income into the Medicare trust fund by limiting compensation beyond health care to say, for instance, executives of trade associations or union leaders or trial lawyers or baseball players or movie stars. But, no; this amendment focuses on one specific group of executives who weren't going to be bought off by this bill. So let's just call this amendment out for the brazen political stunt it is, and if we do that, vote it down.

I wish to remind everyone in closing that I asked the sponsor to include drug company executives in her amendment but was turned down.

I yield the floor and yield 5 minutes to Senator Brownback.

Madam President, I yield 10 minutes to the Senator from Texas.

Madam President, I yield the remaining time to the Senator from Wyoming.

Madam President, I yield to the Senator from Alabama 10 minutes.

Madam President, I yield myself such time as I might consume on this side.

I listened to the distinguished majority whip. I don't know how many times we on this side have to tell him that if they want to read Republican bills here is an opportunity to come and read them. They do exist and they have existed for a long time, going back to some of their entries into the Senate in the spring.

Another thing I heard was that Republicans have no ideas, taking on the insurance companies. I would refer him to the Coburn-Burr bill that does away with the discrimination, that insurance companies cannot deny health insurance because of preexisting conditions.

I heard him say we are newfound supporters of Medicare. Let me suggest to him that when we learned from the complaints of his party 4 years ago, when they were berating the fact that we wanted to take $10 billion out of Medicare and how that was ruining Medicare--we are faced now with $464 billion out of Medicare and we think they have talked out of both sides of their mouth, in the sense that 4 years ago, if Medicare would be hurt if $10 billion were taken out, surely if $464 billion were taken out, it is hurting Medicare.

I rise not to take on the Senate majority whip at this point but I rise because we keep hearing from the other side about how premiums are going to go down. I referred in previous remarks in this past week to a letter sent to Senator Bayh that provides a very comprehensive analysis of what health insurance premiums will look like as a result of this Reid bill now before us.

That reminds me of one other thing the Senate majority whip said, that we want to delay action on this bill. What we want to have is 99 Senators have the time to consider what is in this 2,074-page bill, when you have to remember that in the secrecy of the Senate leader's office, Senator Reid's office, from October 2 until about the Saturday before Thanksgiving, it took that long in secrecy to put two bills together out of two separate committees. That is one Senator putting together the 2,074-page bill we have before us. Don't you think that 99 other Senators ought to have at least that same period of time to consider what is in this bill? I think so.

Anyway, getting back to the increase in premiums and Senator Bayh's letter from the Congressional Budget Office saying that premiums are going to go up, I wonder if anyone has actually read that letter. I hear a lot of people saying this letter proves that premiums would go down under the Reid bill, even though that is not what that letter says. So I am here to tell people what the letter says. The letter makes it very clear that premiums will increase on average 10 to 13 percent for people buying coverage in the individual market. I think you saw a specific figure given by the Senator from Texas, that in his State for a large percentage of the individual market premiums would go up, just for people in the State of Texas.

I have a chart here in case you missed what this letter actually says. The people who keep saying premiums are going to go down conveniently forget to mention this 10 to 13-percent increase that is going to happen for the individual market. No, they would prefer to talk about 57 percent of Americans in the individual market who are going to get subsidies. Yes, it is true. The Government is spending $500 billion of hard-earned taxpayers' dollars in addition to the cuts they are having in home health care that is a pending amendment before the Senate. These cuts and these tax increases cover up the fact that this bill drives up premiums faster than current law.

I repeat, premiums will go up faster under this bill. Supporters of this bill are covering up this increase in costs by then handing out these subsidies. But if you are 1 of the 14 million people who does not get a subsidy--well, what? You are out of luck. You are stuck with the fact that this is 10 to 13 percent more expensive and, coupled with it, an unprecedented new Federal law that mandates that you buy and purchase insurance.

Some may say this is the individual market, it only accounts for a small

portion of the total market. Again, if you are comfortable, as the other side seems to be, with 14 million people paying more under this bill than they would under current law.

I wish to also have you look at the employer-based market. The Congressional Budget Office analysis says this bill maintains the status quo in the small group and large group insurance market. Is this something we ought to be celebrating, maintaining the status quo? Are expectations so low at this point that Democrats are celebrating that this bill will increase premiums for some 14 million people and maintain the status quo for everybody else?

I am being generous in using the phrase status quo, because this bill actually makes things worse for millions of people. This bill is so bad that Democrats are trying to convince the American people that this is more of the same when even that is not the case.

What happened to bending the growth curve? In other words, the inflation we have historically had in health care costs, going up three or four times the rate of inflation, going up now 8 or 9 percent even when we have deflation in the economy at large? What about the President's promise that everyone will save $2,500? According to CBO, almost every small business will pay between 1 percent more or 2 percent less for health insurance. That means compared to what businesses would have paid under current law, this bill will raise premiums 1 percent or maybe decrease them by a whopping 2 percent. That doesn't sound like this bill is providing real relief, and $2,500 in savings for every American, as President Obama pledged repeatedly during the campaign, is not going to happen.

The larger businesses will pay the same or up to 3 percent less for health insurance. Once again, that doesn't sound like relief, it sounds like more of the same. In fact, the Congressional Budget Office has confirmed that between now and the year 2016, premiums will continue to grow at twice the rate of inflation.

I thought Congress was considering health reform to put an end to the unsustainable premium increases. This bill cuts Medicare by $500 billion, raises taxes by $500 billion, restructures 17 percent of our economy, spends $2.5 trillion, and some of my colleagues on the other side of the aisle are celebrating that they have achieved the status quo when in fact the situation will be worse. I thought the status quo was not something that was acceptable to most Members of this body.

Our constituents want to lower costs. That is their main concern. That is what our constituents begged for, lower costs. But this bill fails to address that concern. It raises premiums and, despite offering new ideas throughout the committee process and on the floor, Republicans are being accused of supporting the status quo when our bills are right here for anybody to look at if they think there are not any ideas we would put forth.

The Congressional Budget Office has spoken and it is pretty clear my colleagues across the aisle are not only OK with the status quo, they are OK with making things worse--higher taxes, higher premiums, increased deficits and less Medicare. Just think, we are approaching the Christmas holiday season and a Christmas gift coming from this Senate, with a 2,074-page bill: higher taxes, higher premiums, increased deficits, $464 billion cuts in Medicare and not doing anything about inflation in health care costs. They are celebrating that they spend $2.5 trillion to raise premiums for 14 million people, not bending this growth curve, not cutting costs.

Don't take my word for it. You have to read this letter from the Congressional Budget Office. It is there in black and white as evidenced by the chart I have here.

I yield the floor.

Regular order.

I yield the remaining time on our side to Senator Thune.

Madam President, I yield the remainder of the time to the Senator from South Dakota.

Mr. President, I yield myself such time as I might take. I don't think I am going to speak more than 6 or 7 minutes, for the benefit of my colleagues who may want some of this time.

I want to tell my colleagues why I am supporting the Hatch amendment. In my home State of Iowa there are 64,000 seniors enrolled in Medicare Advantage. These are seniors who have come to rely on lower cost and particularly additional benefits that Medicare Advantage provides, as opposed to traditional Medicare. Yesterday I came to the floor to point out that my colleagues on the other side of the aisle are playing word games to cover up the fact that they are raiding Medicare, cutting benefits by 64 percent for these 11 million seniors who have chosen voluntarily to go on Medicare Advantage as opposed to traditional Medicare. Let me repeat: This bill cuts Medicare benefits, or let's say raids Medicare, by 64 percent for 11 million Medicare beneficiaries.

My friends on the other side of the aisle keep saying they are not cutting and they use these words, ``they are not cutting guaranteed benefits.'' But this is not even the case. Because we have this new independent Medicare advisory board that is set up in this legislation, it is given very specific authority to cut payments to Medicare Part D. This will result in higher costs and less guaranteed benefits for Medicare beneficiaries enrolled in Medicare Part D.

But I want to leave that debate for later. I want to visit with my colleagues now about Medicare Advantage. Mr. President, 64,000 seniors in Iowa and 11 million seniors nationwide do not care about the gobbledy-gook type words we use here in town, as legal as they are-- ``guaranteed benefits'' on the one hand and the words ``additional benefit'' on the other hand. In other words, guaranteed benefits or,

as the other side wants us to believe, somehow additional benefits provided under Medicare.

I say that is Washington nonsense. I want to bring a little bit of Midwestern common sense to this debate. Our constituents want to know that Congress is not cutting Medicare benefits they have come to rely upon and that would include, under Medicare Advantage, dental care, eyeglasses, hearing aids, and other additional benefits provided by this program that they voluntarily chose, Medicare Advantage.

I know that to be the case. I have at least 1,000 letters I have received since last summer on this point. But I want to read one from Miss Purificacion S. Gallardo of Iowa City, IA.

I am writing to urge you to oppose cuts to Medicare

Advantage. . . . This plan was a great help to me when my

late husband, who passed away in May, was hospitalized. . .

. I was able to afford to pay the hospital without going

bankrupt. We seniors who live on a fixed income depend on

our benefits from Medicare Advantage. I am retired and

don't know how I would have managed without [Medicare

Advantage].

Some of my colleagues on the other side of the aisle don't want seniors, even people such as my constituent from Iowa City, Ms. Gallardo, to know that this 2,074-page bill is cutting their benefits. Because the other side will say they are simply cutting so-called overpayments to Medicare Advantage plans. That doesn't make any difference to Ms. Gallardo. They fail to mention, 75 percent of these so-called overpayments must be spent for additional benefits--not only free money for a company to use or free money that benefits a Medicare Advantage recipient without any concern about what it costs--75 percent of these payments must be spent for additional benefits. Then where does the rest of it go? The rest of it comes back to the Federal Treasury. Cuts to these Medicare Advantage payments are, in fact, cuts in Medicare benefits.

I am more than happy to have a debate on how to reform Medicare Advantage payments. We should always be looking for ways to make payments more efficient. But the solution is not to cut benefits by 64 percent, on which seniors have come to rely, to fund an entirely new entitlement program this country can't afford. At a time when seniors are in the midst of the biggest economic crisis since the Great Depression, we should not be debating a bill that forces them to spend more money on health care, and that is exactly what this 2,074-page bill will do. Seniors who lose their Medicare Advantage as a result of this bill may be forced to buy a Medigap plan to fill in all the holes in traditional Medicare. That is why more low-income seniors enroll in Medicare Advantage. The so-called overpayments my colleagues on the other side of the aisle keep decrying help fill in the significant cost sharing and premiums that exist in traditional Medicare.

This bill will force low-income seniors, who pay little to nothing under Medicare Advantage, to come up with $175 per month to buy a Medigap plan. That doesn't sound like that is a very good way to help seniors. That sounds like this bill is paying for an entirely new entitlement program and paying for it, quite frankly, on the backs of 11 million Medicare beneficiaries.

I support the Hatch amendment. Let's take the $120 billion in Medicare Advantage cuts back to the Finance Committee and find a way to improve the program without hurting 11 million seniors.

I yield 5 minutes, as the manager on this side, to Senator Hutchison.

Mr. President, before the Senator from Arizona leaves, on the point he made and the efforts by the members of the other party to strike Medicare Advantage, I have a letter that was sent to members of the Medicare conference on September 30, 2003, with more Democratic signers who are still in the Senate than Republican signers who were in the Senate, which set out all of the reasons Medicare Advantage was so very important and why it needed to have more money put into the year 2003.

For instance, I will read from the letter:

For nearly 5 million Medicare beneficiaries across America,

Medicare Plus Choice--

That is what it was called before Medicare Advantage--

is an essential program that provides high quality,

comprehensive, affordable health coverage. These seniors and

disabled Americans have voluntarily chosen to receive their

health coverage through Medicare HMOs and other private

sector plans because they have excellent value. To preserve

this important option for seniors across the country,

bipartisan legislation was introduced in the Senate as S.

590, the ``Medicare Plus Choice Equity and Access Act.''

Cosponsored by Senators Schumer and Santorum, S. 590 sought

to increase reimbursement rates and add new reimbursement

options. . . .

Et cetera, et cetera. We have plenty of history in the Senate that is bipartisan that we ought to maintain--Medicare Advantage--rather than do an injustice to it, as this legislation before the Senate is trying to do.

I ask unanimous consent to have this letter printed in the Record.

Mr. President, does the Senator from Wyoming want the remainder of our 20 minutes?

I yield 5 minutes to the Senator from Utah, Mr. Hatch.

Mr. President, I yield 2 minutes to the Senator from Florida.

I yield 1 minute to the Senator from Tennessee.

I yield the balance of my time to the Senator from Texas.

Mr. President, I take a back seat to no one on issues associated with improving the lives of seniors and the disabled.

As ranking member on the Aging Committee, I oversaw critical hearings into deep and persistent problems in our Nation's nursing homes. I was the principal author of the Medicare Part D prescription drug bill which is currently providing our seniors and people with disabilities with affordable prescription medications.

On the disability front, one of my proudest achievements is the enactment of legislation I sponsored along with the late Senator Ted Kennedy, the Family Opportunity Act, which extends Medicaid coverage to disabled children.

In large part, through my efforts, the Money Follows the Person Rebalancing

Act, and the option for States to implement a home- and community-based services program were included in the Deficit Reduction Act of 2005.

Along with Senator Kerry, I have introduced the Empowered At Home Act which, among other things, revises the income eligibility level for home- and community-based services for elderly and disabled individuals.

If I thought that the CLASS Act would add to this list of improvements to the lives of seniors or the disabled, I would be first in line as a proud cosponsor of the CLASS Act.

But the CLASS Act does not strengthen the safety net for seniors and the disabled.

The CLASS Act compounds the long-term entitlement spending problems we already have by creating yet another new, unsustainable entitlement program.

The CLASS Act is just simply not viable in its current form.

It is almost certain to attract the people who are most likely to need it--this is known as adverse selection.

That will cause premiums to increase and healthier people to drop out of the program.

It is the classic ``insurance death spiral.''

On November 13, the administration's own Chief Actuary confirmed this. The Chief Actuary issued a dire warning in a report on the CLASS Act in the House bill which is virtually identical to the Senate version.

The Chief Actuary said:

There is a significant risk the problem of adverse

selection would make the CLASS program unsustainable.

The CLASS Act has been characterized by the Washington Post editorial page as a ``gimmick.''

For the first 10 years, the CLASS Act saves money at the beginning because it collects premiums before benefits start getting paid out.

But sometime afterwards, it starts to lose money.

We all know what happens from there. It will become the taxpayers' responsibility to rescue the program as it fails.

Look at the financial struggles of Social Security. Look at Medicare. Look at Medicaid.

Now go home and look at your children and grandchildren.

Voting to protect the premiums of a program that you know will fail is irresponsible.

Creating the unsustainable CLASS Act is irresponsible.

Adding the ticking timebomb of yet another unfunded liability to our children and grandchildren through the CLASS Act is irresponsible.

The responsible vote is to strike the CLASS Act from the bill; I urge my colleagues to support this amendment.

Mr. President, I ask unanimous consent to have printed in the Record two items. First is an article from Fortune magazine on the CLASS Act. Second is a letter signed by seven of my Democratic colleagues objecting to the CLASS Act.

Mr. President, it is late in the evening. I was going to address three different issues tonight, but out of respect for Senator Baucus, the chairman of my committee, I am going to address just one of these issues and I will come back tomorrow morning, on Saturday, and speak on the rest of the issues.

The one issue I am going to address this evening is my support of the Senator from Nebraska and his motion to commit with instructions on the home health care aspect of this 2,074-page bill. That is Senator Johanns' motion. We are now considering a bill that cuts $\1/2\ trillion from a Medicare Program to fund yet another unsustainable health care entitlement program. Around $42 billion comes from cuts to home health care providers--hence the purpose of Senator Johanns' amendment that that not happen.

You have heard from Members on this side of the grave consequences of these cuts. Several Senators have already addressed these. These severe cuts pose a legitimate threat to beneficiaries' access to home health services. In my State of Iowa alone, there are around 160 home health agencies that provide valuable services to Medicare beneficiaries across the State. Thanks to these home health care providers, seniors in Iowa are able to live at home instead of institutional settings, such as nursing homes. These seniors place great value on being able to stay in their homes. I would have to say that in all the years I have been involved in senior issues, whether it has been chairman of the Aging Committee, or chairman and now ranking member of the Finance Committee, I haven't run into one single senior citizen in my State who said to me: I am just dying to get into a nursing home. They do not want to go there.

So that is the purpose of home health agencies, to save money, but it is to retain the quality of life, and maintain the quality of life for these citizens. I rarely hear Iowans say anything about living in a nursing home, except not to go there.

Since living at home has been found to be a more cost-effective alternative than institutional care, this results in Medicare spending less. These cuts that are in this 2,074-page Reid bill will make it even harder for Iowa home health care providers to care for Medicare beneficiaries. A good part of the Medicare home health cuts come from permanent productivity adjustments.

Let's look at the possibility--or I would say I have concluded the impossibility--of bringing greater productivity to nursing home care. You have heard this week about how Medicare's chief actuary found savings from these productivity adjustments to be very unrealistic. And just so you know that the letter I refer to from the chief actuary is real, observe this chart. You also heard this week how these permanent cuts would make it harder for providers to remain in the black. You also heard these providers might end their participation in Medicare and possibly then jeopardize access to care for beneficiaries, and probably then more people ending up in the more expensive environment of a nursing home.

The threat to access to home health care from these permanent productivity cuts isn't theoretical. It is real. Like many other Medicare providers, home health agencies provide labor-intensive services. It is because of these labor-intensive services that I raise the question and the possibility--and I say it ends up being an impossibility--for them to be more productive. There are few gadgets in home health that will increase productivity. And whatever available gadgets there are, they are unaffordable for many Iowa home health agencies because they are small operations with limited financial resources.

Home health care is about doctors, it is about nurses, and home health aides, and it is about all of these providing care to the most needy. So it is incorrect, in my judgment, to assume these providers will achieve the levels of productivity like the rest of the economy.

The HHS chief actuary's findings clearly apply to home health in my State of Iowa, as they do nationally. Just to remind you: ``The estimated savings may be unrealistic;'' and ``possibly jeopardizing access to care for beneficiaries for our seniors.'' More people in nursing homes.

Because of these cuts, the percent of Iowa home health agencies that have negative Medicare margins will increase to 75 percent. So over 120 of the 160 home health providers will have negative Medicare margins because of this 2,074-page Reid bill. Iowa providers are not alone. From \1/2\ to 90 percent of home health agencies in States across the country would have negative Medicare margins.

I ask a unanimous consent to have printed in the Record three letters, which I wish to put in at various places in my remarks.

Mr. President, I have here a letter dated September 23 of this year from Val Halamadaris, the president of the National Association for Home Health and Hospice. This organization represents home health agencies across the country.

Mr. President, Mr. Halamadaris wrote this letter in response to the $43 billion in home health cuts in the Finance Committee package, which presumes to be the same number that is used in the Reid bill. In this letter, he stated:

It is crucial to the survival of the home health services

delivery system that you work to reduce the $43 billion in

cuts currently contained in the Senate Finance Committee's

health reform package. Our analysis indicates that by 2016,

the proposed cuts in home health care services payment rates

will lead to nearly 70 percent of providers nationwide at

risk of closing because their costs will exceed Medicare

payments. If that occurs, President Obama's promise that

Medicare beneficiaries will not be adversely affected by

health care reform will be broken.

I have yet to hear from a home health care provider in Iowa that these permanent cuts will make it easier for them to care for their Medicare beneficiaries. Instead, I hear these cuts would reduce access to home health services.

The second letter I asked to have inserted in the Record is from the Iowa Alliance in Home Care, and they wrote:

Ensuring that Medicare home health payments are not reduced

further is essential to avoid the resulting limited or no

access to home health services for many Iowans who prefer to

receive services in their home.

Not only is the chief actuary saying it, as the chart reflects, but people who are connected with the business of home health care are saying it: These permanent cuts will in fact jeopardize access to home health services in Iowa. So if the home health cuts in the Reid bill are allowed to go into effect, then

Iowa's seniors, who prefer to live full lives from their homes, will be forced to live in the more expensive settings of facilities such as nursing homes.

I believe many Members on both sides of the aisle share my concern about home health care cuts.

I have here a third letter, this one dated from July 27, 2007, and it is written to Senator Baucus and me.

Mr. President, I use this letter, even though it is 2 years old, because we were getting entreaties from 61 of our colleagues--of which 52 now still serve in the Senate--about a legislative proposal to cut Medicare home health payments in that year--2007--by $9.7 billion and hospice payments by more than $1.1 billion. They urged me and Senator Baucus, at that time, to ensure that home health and hospice providers receive full market basket inflation adjustments. They also urged us to oppose any cuts in payment rates through administrative actions.

In the letter, these Members stated that home health and hospice care ``have been demonstrated to be cost-effective alternatives to institutional care in both Medicare and Medicaid programs.'' They stated that ``reducing Medicare home health and hospice payments would place the quality of home health care and hospice and the home care delivery system at significant risk.''

Of these 61 Senators who signed this letter 2 years ago, 52 are currently here debating this bill in the Senate. Of those 52 Senators, 37 are from his side of the aisle who are now proposing $43 billion in cuts instead of $9.7 billion in home payment cuts and $1.1 billion in hospice payments cuts. I would think they would find these kinds of cuts three or four times--four times what we were talking about 2 years ago to be very unrealistic, and to keep home health as a viable organization going.

We also must look beyond health care when we look at the impact of these permanent cuts. I have also heard from providers in Iowa that permanent cuts such as these will make it even harder for them to keep their doors open. So around 3,500 Iowans who work at home health agencies are at risk of losing their jobs at a time when we have 10 percent unemployment, at a time when more of this country is concerned that Congress ought to be working on creating jobs, jobs, jobs as opposed to the health care issue and in some cases cutting jobs out. The Labor Department reported today that unemployment is 10 percent. Now is not the time to consider bills that increase unemployment rates.

About an hour ago, the Senator from Nebraska offered this motion I am speaking in favor of now, to send this bill to the Finance Committee with instructions to report a bill without these very enormous home health cuts that are in it. We should take this opportunity to fix the bill and then come back to the full Senate with a better bill. That is why I support the motion of the Senator from Nebraska to commit, and I urge my colleagues to do the same.

I yield the floor.

Exhibit 1

National Association

for Home Care & Hospice,

Washington, DC, September 23, 2009.

Re Medicare Home Health Services.

Hon. Charles E. Grassley,

U.S. Senate,

Washington, DC.

Dear Senator Grassley: I am writing to thank you for your

continued support of home care patients nationwide and to

enlist your help to ensure that access to home health

services remains a reality for more than 3 million senior and

disabled individuals that benefit from these important

services.

It is crucial to the survival of the home health services

delivery system that you work to reduce the $43 billion in

cuts currently contained in the Senate Finance Committee's

health reform package. Our analysis indicates that by 2016,

the proposed cuts in home health services payment rates will

lead to nearly 70% of providers nationwide at risk of closing

because their costs will exceed Medicare payments. If that

occurs, President Obama's promise that Medicare beneficiaries

will not be adversely affected by health care reform efforts

will be broken.

Invariably, providers of services facing rate cuts always

cry out that care will be lost. However, history tells us

that our warning should be heeded. The Balanced Budget Act of

1997 was expected to cut home health services spending by

$16.1 billion in five years. Instead, the rate changes cut

over $70 billion, leading to the loss of care to nearly 1.5

million Medicare beneficiaries. That change also led to

higher outlays under state Medicaid programs, as well as

greater use of nursing homes, hospitals, and other

institutional settings. Still today, about $17 billion is

spent on home health services, as compared with about $19

billion in home health outlays in 1997.

Several factors need to be understood about the current

Finance Committee proposal. First, the proposal is not

consistent with MedPAC advice. The proposal reduces rates to

a point where Medicare margins will average zero. MedPAC, in

its deliberations, clearly recognized the need for some level

of margin in order to stay in business. In fact, we

understand that MedPAC's executive director, Mark Miller,

informed House Ways and Means members that MedPAC did not

recommend a zero margin.

Second, there is a serious misunderstanding of Medicare

margins. MedPAC estimates margins for 2009 will be 12.2%.

However, this estimation does not include the impact of

nearly 7% in rate reductions planned by way of regulation by

2011. Further, it does not include nearly 1,700 important

providers of home health services, hospital-based agencies.

Also, it does not reveal that the ``average'' is made up of a

very wide range of individual agency margins with over 30%

below zero already. Finally, reliance on Medicare margins

does not convey that the total margin of agencies is

estimated at 2% with Medicaid and Medicare Advantage losses

driving the overall margin down.

Third, unlike other health care providers such as

hospitals, the expansion of health insurance will not bring

additional business of any material level. Home health

patients average nearly 80 years of age and are already

insured by Medicare or Medicaid. This means that the Medicare

cuts to home health agencies are not offset by new revenues

from newly insured patients. Instead, the proposed cuts of

over 13.5% of spending on home health services will be as

real as can be.

Fourth, the home health services community has put forward

a credible and substantive alternative set of proposals for

reforming the Medicare payment system. While the Chairman's

Mark incorporates many of these proposals, the level of cuts

is unsustainable. In fact, the level of cuts exceeds the $34

billion President Obama's budget recommended by nearly $10

billion. Still, the industry's proposal itself meets or

exceeds the Obama budget target.

Fifth, the home health services cuts are far

disproportionate to other provider sectors. The Chairman's

Mark seeks 9.4% of all the Medicare cuts from home health

care while home health makes up only 3% of the Medicare

program currently. That disproportionate impact is further

magnified by the fact that, unlike most other health care

providers and insurers, expanding health insurance will have

no meaningful increase in home health care business.

This is a historic time in this country, an opportunity to

secure health care for all as a fundamental right. However,

these reforms should not be done at the expense of our most

vulnerable senior citizens, the homebound and infirm. Your

leadership on this matter is greatly appreciated. Please let

us know what we can do to help you succeed.

You have my great respect and admiration, now and always.

Sincerely,

Val J. Halamandaris,

President.

Exhibit 2

Iowa Alliance in Home Care,

Des Moines, IA, December 4, 2009.

Hon. Charles Grassley,

Ranking Member, Committee On Finance, Dirksen Senate Office

Building, Washington, DC.

Senator Grassley: I'm contacting you today to urge your

assistance concerning an issue of great significance to

Iowa's dedicated home care nurses and other providers of

valuable and needed in-home health care services to Iowans.

The Iowa Alliance in Home Care respectfully requests your

support to have the Senate Finance committee report back to

the Senate, in response to a motion with instructions, a

modified H.R. 3590 bill that does not include cuts in

Medicare payments to home health agencies totaling $42.1

billion.

Your urgent action is critically important to ensure that

access to quality health care services delivered in the home

setting is not compromised. Proposed cuts in Medicare home

health reimbursement would be devastating as most of Iowa's

home care providers (i.e. public health departments, small

businesses) rely largely or exclusively on Medicare and

Medicaid payment to justify their operations which includes

employment for thousands of Iowans. Insufficient Medicaid

home health reimbursement, recently worsened by Governor

Culver's ATB state budget cuts, has been reduced by an

additional 5% effective 12/1/2009. In short, ensuring that

Medicare home health payments are not reduced further is

essential to avoid the resulting limited or no access to home

health services access for many Iowans who prefer to receive

services in their own home.

Senator, thank you for your past home health care support.

We would greatly appreciate your immediate attention to this

most critical of needs for our Iowa home health care

community.

Regards,

Mark Wheeler,

Executive Director.

Exhibit 3

U.S. Senate,

Washington, DC, July 27, 2007.

Hon. Max Baucus, Chairman,

Hon. Charles Grassley, Ranking Member,

Senate Finance Committee,

Washington, DC.

Dear Chairman Baucus and Ranking Member Grassley: Home

health and hospice have become increasingly important parts

of our health care system. The kinds of highly skilled and

often technically complex services that our nation's home

health and hospice agencies provide have enabled millions of

our most frail and vulnerable seniors and disabled citizens

avoid hospitals and nursing homes. By preventing such

institutional care, home health and hospice services save

Medicare millions of dollars each year. Most importantly,

they enable individuals to stay just where they want to be--

in the comfort and security of their own homes. We therefore

urge you to ensure that Medicare beneficiaries continue to

have access to important home health and hospice services by

supporting full market basket inflation adjustments, as

provided under current law, and opposing any cuts in payment

rates through administrative actions.

The Administration's FY 2008 budget includes a legislative

proposal to cut Medicare home health payments by $9.7 billion

and hospice payments by more than $1.1 billion over five

years. It also includes additional administrative cuts in

payment rates. The Medicare home health benefit has already

taken a larger hit in spending reductions over the past ten

years than any other Medicare benefit. In fact, home health

as a share of Medicare spending has dropped from 8.7 percent

in 1997 to 3.2 percent today, and is projected to decline to

2.6 percent of Medicare spending by 2015. This downward

spiral in home health spending began with provisions in the

Balanced Budget Act of 1997 (BBA), which resulted in a 50

percent cut in Medicare home health spending by 2001--far

more than the Congress intended or the Congressional Budget

Office (CBO) projected.

We believe that further reductions in home health and

hospice payments would be counterproductive to controlling

overall health care costs. Home health and hospice care have

been demonstrated to be a cost-effective alternative to

institutional care in both the Medicare and Medicaid

programs. In fact, the Medicare Payment Advisory Commission

(MedPAC) has noted the results of a 2002 RAND study which

showed ``in terms of Part A costs, episodes in an inpatient

rehabilitation facility or skilled nursing facility are much

more costly for Medicare than episodes of care among patients

going home.'' (MedPAC's June 2005 Report to Congress).

Further reducing Medicare home health expenditures would

also be in direct conflict with the Administration's desire

to prioritize health care in the home as a cost-effective

alternative to institutional care. During the World Health

Congress in February of 2005, Secretary of Health and Human

Services Michael Leavitt said: ``Providing the care that lets

people live at home if they want is less expensive than

providing nursing home care. It frees up resources that can

help other people. And obviously, many people are happier

living at home.''

Reducing Medicare home health and hospice payments would

place the quality of home health care and hospice and the

home care delivery system at significant risk. Several

factors have contributed to the increased cost of providing

care in the home over the past few years, including:

The cost of travel by clinicians to patients' homes;

The use of technology, like telehealth monitors, which is

not covered by Medicare;

The need to pay significantly higher salaries for nurses,

therapists, and home health aides to attract these

individuals from the scarce supply of clinicians nationwide.

Many home health providers currently do not have a

sufficient number of clinical staff to accept patient

referrals from physicians and hospitals. As a consequence,

hospital discharge planners have reported that they are

finding it more difficult to refer patients for home health

care. Additional cuts to the home health benefit could leave

home health providers no alternative but to reduce the number

of visits and/or patient admissions, which would ultimately

affect access to care and clinical outcomes. In addition to

these costs, hospices are also experiencing rising costs for

pain management pharmaceuticals, and they are also finding

that patients with shorter lengths of stay are requiring more

intensive services.

In order to ensure that home health care and hospice remain

a viable option for Medicare patients, we urge you to support

full market basket updates for home health and hospice, as

provided under current law, and to oppose any cuts in payment

rates through administrative action. Thank you for your

consideration of this important matter.

Sincerely,

Susan M. Collins; Russ Feingold; Christopher S. Bond;

Jack Reed; Patrick J. Leahy; Arlen Specter; Norm

Coleman; Sheldon Whitehouse; Robert Menendez; Ken

Salaar; Barack Obama; Kent Conrad; Thomas R. Carper;

Barbara Mikulski; Joe Lieberman; E. Benjamin Nelson;

Daniel K. Inouye; Tom Harkin; Robert C. Byrd; Frank

Lautenberg; Amy Klobuchar; Herbert Kohl; Byron L.

Dorgan; Daniel K. Akaka; Barbara Boxer; Tim Johnson;

Johnny Isakson; Evan Bayh; Jim Webb; Patty Murray;

Chuck Hagel; Joseph R. Biden, Jr.; Robert P. Casey,

Jr.; John F. Kerry; Hillary Rodham Clinton; Sherrod

Brown; Christopher J. Dodd; John Thune; Carl Levin;

John W. Warner; Saxby Chambliss; Ron Wyden; Mark L.

Pryor; Maria Cantwell; Robert F. Bennett; Bernard

Sanders; Charles E. Schumer; Richard G. Lugar; Dianne

Feinstein; Larry E. Craig; John Cornyn; Benjamin L.

Cardin; Edward M. Kennedy; Pete V. Domenici; Bill

Nelson; Kay Bailey Hutchison; David Vitter; Pat

Roberts; John E. Sununu; Mary Landrieu; Sam Brownback.

When they reach age 65, they will have that benefit.

To the tune of 2.9 percent of payroll. That is how much a self-employed person would pay. And an employee would pay 1.45 percent and the employer would pay 1.45 percent. Then, you know this 2074-page bill adds half a percentage point to those, so you are going to get it to a point where it is almost 2 percent for the employer, 2 percent for the employee, and it would be almost 4 percent for a self- employed person paying into this that is now going to be raided to finance a brandnew entitlement program.

I sense a great deal of resentment coming through in that letter, from the words of that letter from that person, that what he has paid into, for the probably 45 years of working before he retired--that now, with Medicare already being in jeopardy, based on the trustees' report which says that by 2017 there is not going to be any money in the trust fund, and then having $464 billion taken out of that trust fund to help finance a new entitlement program at a time when the present entitlement programs are in a great deal of financial jeopardy.

No. The only way he would have gotten benefits is if he had become disabled before age 65.

I say it this way. We are in a town where we are dealing with a lot of Washington nonsense, and I hope, from the rural areas of Alabama, like the State of Iowa, you bring a lot of common sense to this town where there is not a lot of it.

Mr. President, I would like to also make a statement related to the amendment that is being presented by the Senator from Colorado. Speaking for several Members on my side--hopefully, for all the Members on my side--we are very concerned, as I think we have all made clear by now, that the Medicare savings in this bill are being used not for preserving Medicare but, instead, are being used to finance the creation of a new Federal entitlement program.

My understanding of the purpose of the amendment of the Senator from Colorado is to indicate that Medicare savings will be used for extending the solvency of Medicare and the trust fund, reducing Medicare premiums and other cost sharing for beneficiaries, and to improve or expand Medicare benefits and access to providers.

Nobody can argue with that purpose the Senator has expressed or his amendment expresses. But the concern on our side that we have with this amendment is it does not require that the savings from Medicare would only--with emphasis upon the word ``only''--be used for that purpose.

As the Congressional Budget Office has made clear, the cuts in Medicare in this bill are not being used solely for Medicare, as the Senator's amendment suggests, but, instead, are being used

mostly to fund the creation of an entirely new and separate subsidy program. For the Senator to accomplish what he intends to accomplish would require entirely different language to ensure that savings from Medicare in this bill would only be used to protect Medicare benefits for seniors, as the law now expresses.

The right approach would include language making sure seniors have the same access as they have today, to home health services, skilled nursing facilities and services, hospice care, hospital services, preventive benefits, and the benefits provided in the Medicare Advantage Program. So the Senate, it seems to me, should also ensure that Medicare savings in this bill are not being siphoned off to finance a new and separate entitlement program.

It is very clear to me--and I hope we are able to make it clear to people, all 100 Senators--that the Bennet amendment, as written, does not protect Medicare.

I yield the floor.

Mr. President, I will take a short minute to respond to a question. But our side has 7--

Could we discuss this maybe a little bit later, what you brought up?

OK.

That is true. But I do not think the Senator wants to go down that road because, do not forget, there are 6 years of programs, of expenditures, and there is 10 years of revenue coming in. If you want to play that game, you can pay down the entire national debt.

I cannot respond to that because I do not know that for sure. So I do not want to respond. But if you tell me, I tend to believe everything you tell me.

Mr. President, as I stated earlier, the Bennet amendment, as written, does not protect Medicare. So I have a modification I would like to present that ensures Medicare savings in this bill are not being siphoned off to finance a new and separate entitlement program.

To that end, I ask unanimous consent to modify the amendment by adding the following before the period at the end of subsection (b):

. . . and furthermore that, notwithstanding any other

provision of this Act or amendment made by this Act, net

Medicare savings specified in the most recent estimate

available from the Director of the Congressional Budget

Office before enactment are appropriated to the Secretary and

shall be used for such purposes and to maintain Medicare

policies for home health services, skilled nursing facility

services, hospice care, hospital services, and benefits

provided by the Medicare Advantage program, as under the

provisions of such Title as specified on the day before the

date of enactment of this Act.

End of my amendment.

Then if I may?

Mr. President, I would like to make very clear that this objection confirms that the Bennet amendment does not protect Medicare as the other side claims that it protects Medicare.

I yield the floor.

Mr. President, today I am introducing the Clean Renewable Energy Advancement Tax Extension Jobs Act of 2009, or the CREATE Jobs Act of 2009 for short. This is a bill to help all kinds of businesses create jobs and continue pushing ahead on the development of clean renewable energy. My bill extends the tax credit for the production of electricity from wind and open-loop biomass through December 31, 2016.

It increases the amount of bond authority for new clean renewable energy bonds to incentivize more clean renewable energy projects and the jobs created by these projects. For all businesses, my bill extends bonus depreciation for 1 year, so that businesses are able to deduct half of the value of any property placed in service in 2010.

This tax cut for businesses that invest in new property in 2010 will spur investment in clean energy projects, as well as other new projects, and that will create badly needed jobs.

I urge my colleagues to help me in getting this important legislation enacted into law as soon as possible.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, today I am introducing the Clean Renewable Energy Advancement Tax Extension Jobs Act of 2009, or the CREATE Jobs Act of 2009 for short. This is a bill to help all kinds of businesses create jobs and continue pushing ahead on the development of clean renewable energy. My bill extends the tax credit for the production of electricity from wind and open-loop biomass through December 31, 2016.

It increases the amount of bond authority for new clean renewable energy bonds to incentivize more clean renewable energy projects and the jobs created by these projects. For all businesses, my bill extends bonus depreciation for 1 year, so that businesses are able to deduct half of the value of any property placed in service in 2010.

This tax cut for businesses that invest in new property in 2010 will spur investment in clean energy projects, as well as other new projects, and that will create badly needed jobs.

I urge my colleagues to help me in getting this important legislation enacted into law as soon as possible.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Madam President, on Monday the Congressional Budget Office sent a letter to the Senator from Indiana, Mr. Bayh, that provides a very comprehensive analysis of what health insurance premiums will look like as a result of this 2,074-page bill before us, introduced by Senator Reid. Listening to that discussion, I am starting to wonder if anyone actually read the letter. I hear a lot of people saying this letter proves that premiums will go down under the Reid bill, even though that is not what the letter says. I am here to tell my colleagues what the letter really says.

The letter makes it very clear that premiums will increase on average by 10 to 13 percent for people buying coverage in the individual market. Since it seems to fly by everybody what this letter actually said about increasing premiums, I brought down a chart to show everyone in case they missed it.

The letter from the CBO says very clearly that for the individual market, premiums are going to go up 10 to 13 percent. My colleagues keep saying premiums are going to go down, conveniently forgetting, then, to mention this 10- to 13-percent increase. They prefer to talk about the 57 percent of Americans in the individual market who are getting subsidies. It is true that government is spending $500 billion in hard-earned taxpayer money to cover up the fact that this bill drives up premiums faster than current law. So we might as well repeat it: Premiums will go up faster under this bill.

Supporters of this bill are covering this increase in cost how? By handing out subsidies. If you are one of the 14 million who doesn't happen to get a subsidy, you are out of luck. You are stuck with a plan that is 10 to 13 percent more expensive and also, simultaneous with it, an unprecedented new Federal law that mandates that you purchase insurance. If you don't purchase insurance, you are going to pay a penalty to the IRS every time you file your income tax. Some may say this is just the individual market. It only accounts for a small portion of the total market. If you are comfortable with 14 million people paying more under this bill than they would under current law, let's look at the employer-based market.

The Congressional Budget Office analysis says this bill maintains the status quo in the small group and large group insurance market. Is that something to be celebrating? Are expectations so low at this point that my friends on the other side of the aisle are celebrating that this bill will increase premiums for some and maintain the status quo for everyone else? I am being generous in using the phrase ``status quo'' because this bill actually makes things worse for millions of people. This bill is so bad that my friends on the other side of the aisle are trying to convince the American people that this is just more of the same, when that doesn't happen to be the case.

Whatever happened to bending the growth curve? If that is too Washingtonese for people, the goal around here of a bill at one time was to make sure the inflation in insurance didn't continue to go up so much that it would go the other way.

Then what about the President's promise that everyone would save $2,500? According to the Congressional Budget Office, almost every small business will pay between 1 percent more to 2 percent less for health insurance. That means, of course, that compared to what businesses would have paid under current law, this bill will either raise premiums 1 percent or decrease them a whopping 2 percent. It doesn't sound like this bill is providing any real relief or, for sure, not providing $2,500 savings for every American, as President Obama repeatedly pledged during the campaign. Larger businesses will pay the same or up to 3 percent less for health insurance. Once again, that doesn't sound like relief; it sounds like more of the same.

In fact, the Congressional Budget Office has confirmed that between now and 2016, premiums will continue to grow at twice the rate of inflation. I thought Congress was considering health reform to put an end to unsustainable premium increases.

So this bill cuts Medicare by $500 billion, raises taxes by $500 billion, restructures 17 percent of our economy, and spends $2.5 trillion. Yet some of my colleagues on the other side of the aisle are celebrating that they have achieved the status quo when, in fact, the situation will be worse. I always thought the status quo was unacceptable. I thought businesses could not afford the status quo. I thought the status quo was killing American businesses, killing jobs, and making this country less competitive. But Member after Member keeps coming down to the floor to celebrate spending $2.5 trillion on the status quo. We could have done that for free. Am I missing something? Did people really read the same letter I did from the CBO?

When President Obama visited Minneapolis in September, he didn't sound as though he was celebrating maintaining the status quo. On the contrary, I have a chart with one of his quotes:

I will not accept the status quo. Not this time. Not now. .

. .

Some Members seem to disagree. Some Members are celebrating that they are making things worse for millions of Americans and maintaining the status quo for everyone else.

Here is what Vice President Biden said:

The status quo is simply unacceptable. Let me say that

again--the status quo is simply unacceptable. Rising costs

are crushing us.

That doesn't sound like a call for more of the same. Once again, Members on the other side of the aisle seem quite comfortable investing $2.5 trillion in more of the same. That is taxpayer dollars we are talking about.

If I asked most Iowans how they would feel about government spending $2.5 trillion and premiums would still increase as fast or faster, they would say that was a pretty bad investment. Well, I will not argue with what our constituents would say on that point. I agree with them.

This Congressional Budget Office letter tells me that we are debating a pretty bad investment. Our constituents want lower costs. That is their main concern. But this bill fails to address that concern because it raises premiums. Despite offering new ideas throughout the committee process and on the floor of the Senate, Republicans are being accused of supporting the status quo. CBO has spoken, and it is pretty clear that my colleagues are not only OK with the status quo, they are OK with making things worse: higher taxes, higher premiums, increased deficit, less Medicare. They are celebrating that they spent $2.5 trillion to raise premiums for 14 million people, not bending the growth curve of inflation in health care, and not cutting costs. Don't take my word for it. Read the letter. Read the letter from the Congressional Budget Office. I have copies I will pass out if anybody wants them. I have this chart that demonstrates that point.

I also wish to take a few minutes at this time to correct some inaccurate comments made earlier by some of my colleagues. When we are talking about 17 percent of the economy and something that touches the lives of every single American, I want to make sure we have an honest and accurate debate. This morning I heard at least three Members on the other side of the aisle say that Medicare Advantage is not part of Medicare. This is totally false.

But don't take my word for it. I would like to have Members turn to page 50 of the handbook,''Medicare and You.'' Presumably it has the date of 2010 on it. It is sent out every year. In fact, I think I have two copies of this in my household. If anybody wants to save paper and not waste taxpayer money, they can get on the Internet and tell them only to send one to their house next year. I have done that.

This book says, for those who say Medicare Advantage is not part of Medicare:

A Medicare Advantage plan is another health coverage choice

that you may have as part of Medicare.

I repeat, despite what Members were saying earlier, the ``Medicare and You'' handbook says very clearly: Medicare Advantage Plans are part of Medicare. So if you are cutting Medicare Advantage benefits, you are, in fact, cutting Medicare benefits.

Next, I hear a lot of Members talking about guaranteed benefits versus statutory benefits. I can't speak for my other 99 colleagues, but the seniors in Iowa who have come to rely upon the free flu shots, eyeglasses, and dental care that Medicare Advantage provides don't care if they are guaranteed or if they are statutory. Seniors in Iowa just want to know they will still have

these benefits after health reform is passed.

The Senator from Connecticut challenged any Member to come down to the Senate floor and point out where this bill will cut benefits. He even read a section from page 1,004 of this 2,074-page bill that talks about how the Medicare Commission cannot cut benefits or ration care. I have read page 1,004. What Senator Dodd failed to mention is that this section only refers to Parts A and B of Medicare. It fails to provide any protection to Medicare Part D, the prescription drug benefit, or the Medicare Advantage Program that covers 11 million seniors.

Are we now going to start hearing that Medicare Part D is not part of Medicare either? In fact, on page 1,005, it specifically says the Medicare Commission can ``[i]nclude recommendations to reduce Medicare payments under parts C and D.''

I have asked CBO, and they have confirmed this authority could result in higher premiums and less benefits to seniors. In fact, this is what Congressional Budget Office Director Elmendorf said, and we have that on a chart for you to see the quote I am going to read: ``A reduction in subsidies to [Part D] would raise the cost to beneficiaries.''

Lastly, I wish to raise an issue about access to care. I keep hearing my friends on the other side of the aisle talk about how these cuts will not affect seniors. They say they are just overpayments to providers. Well, in my opinion, if you cannot find a doctor or if you cannot find a home health provider or a hospice provider to deliver care, then that tends to be a very big problem. I would even consider that a cut in benefits or hurting access to care.

But, once again, do not take my word for it. In talking about similar cuts to Medicare in the House bill, the Office of the Actuary at the Centers for Medicare & Medicaid Services said providers that rely on Medicare might end their participation, ``[p]ossibly jeopardizing access to care for beneficiaries.''

So let's be accurate and let's be honest. Medicare Advantage is part of Medicare, and this bill cuts benefits seniors have come to rely upon. The Medicare Commission absolutely has authority to cut benefits and to raise premiums, and this bill will jeopardize that access to care.

Those are all facts. They are not my facts but facts taken directly from the language of this 2,074-page bill and from reports of the Congressional Budget Office and the Office of the Actuary at the Centers for Medicare & Medicaid Services.

I yield the floor.