Floor Statements

Mr. President, I ask unanimous consent that the Senator from Nebraska be allowed to speak for up to 10 minutes.

Mr. President, I yield to the Senator from California. At least indirectly it is our understanding that Senator Reid will soon come to the floor to speak.

That would be my request.

Mr. President, the McCain motion to commit on Medicare Advantage would keep overpayments in the Medicare Advantage program, even though the Medicare Payment Advisory Commission recommends that they be eliminated.

The McCain motion to commit is a tax on all seniors. It would maintain the overpayments to private insurers and require beneficiaries to pay higher Part B premiums. The average couple pays $90 per year just so insurers can reap greater profits under Medicare.

The McCain amendment is a raid on the Medicare trust fund. MA overpayments take 18 months off the life of the Part A trust fund. And according to MedPAC, there is no evidence of greater quality of care. In fact, MedPAC told Congress this year that ``only some'' MA plans are of high quality. MedPAC finds that ``only half of beneficiaries nationwide have access to a plan that Medicare rates above average on overall plan quality.''

The more than 45 million seniors with Medicare deserve better. They do not deserve to subsidize high profits of private insurers. And the more than 11 million Medicare beneficiaries who choose to enroll in private plans also deserve better. They deserve plans that coordinate care. Most plans today do not. They deserve plans that are of high quality. Many plans today do not.

If Senators want to help beneficiaries, they will vote to eliminate overpayments under Medicare Advantage. And they should vote against the McCain motion.

Mr. President, I ask unanimous consent that the Committee on Armed Services be authorized to meet during the session of the Senate on December 8, 2009, at 1:30 p.m.

Mr. President, I ask unanimous consent that the Committee on Environment and Public Works be authorized to meet during the session of the Senate on December 8, 2009 at 10 a.m. in room 406 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Committee on Foreign Relations be authorized to meet during the session of the Senate on December 8, 2009, at 2:15 p.m.

Mr. President, I ask unanimous consent that the Select Committee on Intelligence be authorized to meet during the session of the Senate on December 8, 2009, at 2:30 p.m.

Mr. President, I ask unanimous consent that the Subcommittee on Energy be authorized to meet during the session of the Senate in order to conduct a hearing on December 8, at 2:30 p.m., in room SD-366 of the Dirksen Senate Office Building.

Mr. President, for the benefit of all Senators, I will take a moment to lay out today's program. It has been 2\1/2\ weeks since the majority leader moved to proceed to the health care reform legislation. This is the eighth day of debate. The Senate has considered 16 amendments and motions and conducted 12 rollcall votes.

Today, we will debate an amendment by Senator Pryor and, at the same time, an amendment by Senator Gregg to do with spending taking effect. The first 2 hours will be equally divided. The Republicans will control the first 30 minutes and the majority will control the next 30 minutes. There may or may not be a side-by-side amendment to the Gregg amendment. The Senate will conduct votes on or in relation to the Pryor and Gregg amendments this afternoon. We expect at least those votes to begin sometime between 3:15 and 4 p.m. this afternoon.

I will take a few moments to discuss the amendment Senator Gregg offered yesterday. The Gregg amendment has been billed as protecting Medicare. That seems to be the new fashion on the other side of the aisle--to say that the bill cuts Medicare. Frankly, that is a misleading statement at best, and it is inaccurate, basically. In reality, the Gregg amendment is a killer amendment. It is designed to prevent health care reform from taking effect. That is the purpose of the Gregg amendment. It is a killer amendment.

The amendment has more details to it, but you can get the flavor of it from a few excerpts. Let me quote from the amendment.

The first subsection of the amendment is entitled ``Ban on New Spending Taking Effect.'' You really don't have to go much further to get an idea of what the amendment is about. Just focus on that statement in the amendment--a ban on new spending taking effect.

Let me quote further from the second subsection:

. . . the Secretary of the Treasury and the Secretary of

Health and Human Services are prohibited from implementing

the provisions of, and amendments made by, sections 1401,

1402, 2001 and 2101. . . .

What are those sections? The Gregg amendment will stop this spending from taking effect.

Section 1401 is refundable tax credits providing premium assistance for coverage. Those are the tax credits, the tax reductions that help people buy health insurance. The Gregg amendment says we cannot help people buy health insurance, that they can't have those tax credits.

The second section is 1402. What is that? It is to reduce cost sharing for individuals. That is the part that would make copays and other out-of-pocket expenses affordable. The Gregg amendment says: No, we can't have reduced cost sharing for individuals. We have to keep those copays in effect and out-of-pocket expenses high. It would help people with copays and other out-of-pocket expenses.

The third section the Gregg amendment would stop is section 2001. It is a section that provides Medicaid coverage for the lowest income population. That is the one that provides expanded Medicaid coverage up to 133 percent of poverty. The Gregg amendment says: No, you can't help poor people with health care. The Secretary is prohibited from making those payments to Medicaid if that amendment is adopted.

The fourth section the Gregg amendment would stop is section 2101. Section 2101 is a section that provides additional funding for the Children's Health Insurance Program. Can you believe that? A Senator gets up on the floor of the Senate and wants to stop funding to the Children's Health Insurance Program? That is what that section provides.

So if you don't like tax reductions to help people buy health insurance, if you don't like making health insurance affordable, if you don't like health care for the lowest income Americans, and if you don't like health care for kids, then the Gregg amendment is for you.

The folks on the other side of the aisle have spent a lot of time this year talking about Medicare. That is about all I hear from them. They make it sound as if they want to help Medicare. In effect, they are hurting it. A lot of folks say they want to help Medicare, and I see the big crocodile tears they shed. I will take a few moments to set the record straight about how the trust fund works. That might help them understand, frankly, why the bill before us--the Reid bill--helps Medicare, contrary to protestations of those on the other side.

The Medicare trust fund provides hospital insurance for seniors and Americans who are disabled. Working Americans pay into that trust fund when they pay their payroll taxes.

When a senior has to go to the hospital or a nursing home--there are lots of areas where seniors get help--the spending to help pay for that hospitalization comes out of the trust fund. The actual sum comes out of Medicaid, but some payments come out of the Medicare trust fund, such as for home health care, et cetera.

When payroll tax revenues are greater than the payments for hospitalizations, the assets in the Medicare trust fund grow. That is good. On the other hand, when spending for hospital care is greater than payroll tax revenues and interest payments on the trust fund assets, then assets in the Medicare trust fund diminish. That is not good.

The Actuary for Medicare--the person charged with determining the health of the Medicare trust fund over at HHS--tells us that if we don't do anything--if this legislation is not passed--then by about 2017 the Medicare trust fund assets will be exhausted. That is clear. That is definite. That is a fact, and I emphasize the word ``fact.'' I am just being honest, Mr. President. I have to be objective and honest about this stuff. When I hear Senators talk about Medicare, they are not looking at facts. It is one thing to say something and engage in all this rhetoric, but if it is not backed by facts, it is a bit irresponsible.

The fact is, the life of the Medicare trust fund will be extended for 5 years under this legislation. I talked to a Senator on that side privately. He said that the Medicare trust fund will not be extended-- the solvency--for 5 years. I asked him privately: How can that be true? Did you read the Actuary's report? By the way, it was not this Senator right here; it was another Senator, and that Senator said: I don't believe it. It is a fact. The Actuary says that will be the result of the legislation before us; namely, that the solvency of the trust fund will last 5 more years. That is a fact. That is what the Actuary's report said.

So we can either raise more payroll taxes to continue the solvency of the trust fund so that seniors get their benefits or we can reduce spending out of the trust fund. We can either increase the money or decrease the money coming out.

I will say it again. The Medicare Actuary tells us that health care reform will extend the life of the Medicare trust fund by 5 years or, to put it another way, if we do not enact health care reform, we will hurt Medicare's long-term solvency.

Let me cite some examples on how that works.

Health care reform would discourage hospital readmissions, for example. That is waste. See, here is what the other side doesn't quite understand. You don't hear them talking about it. The goal here is to extend the life of the trust fund, basically by cutting out waste--not hurting seniors but cutting out waste and cutting back on overpayments in some areas where some providers are overpaid, and where seniors are helped, not hurt.

Again, here is an example: hospital readmissions. If you can discourage hospital readmissions, that is fewer dollars wasted out of the trust fund, and it is better health care for seniors. The incentive is for hospitals to have more readmissions because that is how they make money. Some hospitals, frankly, don't go out of their way to prevent readmissions because they can make more money that way, although it is not good care for seniors.

When a senior is discharged from a hospital, you want to make sure there is a flow, a seamless effort of keeping health care for that patient, whether it is extended care or home health care in a nursing home or whatnot, and there is a physician involved and nurses involved and so forth, making sure the patient is taking his or her medication, and it is just to make sure patients are getting better all the time.

We all know--I know because I have experienced it, and I have watched it firsthand, and I have heard many people talk about this--that too often, when a patient is discharged, the care for that patient is not as great, as the hospital is in longer involved, and sometimes the regular doctor is not involved because that doctor is not very much involved with the patient at the hospital. My own view is that it needs improvement. It is not working too well.

Again, we are saving dollars in the Medicare trust fund by preventing excessive readmissions. That is wasteful and doesn't help the patient. So that is a way we are saving and extending the solvency of the trust fund. That is one way. There are others. I will cite a second.

Health care reform discourages hospital-acquired infections. I think in America, unfortunately--and I don't know the facts, but I have read this somewhere, but I haven't confirmed it--the rate of infections in American hospitals is greater than it is for other industrialized countries. That is clearly a problem. People die from infections in hospitals, and it seems to me that the more we can encourage fewer infections--one way is through health care reform. Maybe we can lower payments to hospitals that have too many infections. I know it is hard to do. It is a judgment call. You have to do the best you can. That, too, will help the solvency of the trust fund and help care for patients. That is another way we are extending solvency of the trust fund.

I see my good friend from Wyoming on the floor, Senator Barrasso, who talks about home health care. I am sure he wants to eliminate fraud in home health care. I am sure he does. We all want to. So we cut back on areas where there is fraud. Where is there fraud? In outliers. Too many hospitals bill too much for outlier payments, additional payments, because they say they have a special patient who is an outlier. One county in Florida billed for 60 percent of the outlier payments in America even though they had 1 percent of seniors in America. There are other examples like that. The GAO came to us and said we have to do something about this. There is fraud in the home health care program. I am a big fan of home health care--a big, big fan. They do very good work. But we want to take out the fraud--excessive payments that are fraudulent. Isn't that a good thing? Doesn't that extend the solvency of the trust fund? Isn't that helping patients instead of hurting them?

There are examples. The home health folks came to us and said: Make some of these changes because it is more efficient and we can give better care. As a result, fewer dollars are going to home health care. We also had a provision for rural health care. We add an extra bonus for rural health care.

My point is simply that when Senators stand up on the floor and say we are cutting Medicare--sometimes they use the words ``cutting benefits'' or ``hurting beneficiaries''--that is patently false. It is not true. It is true that in some cases we are taking some of the fraud out. It is also true that in some cases we are taking excessive payments--not by our judgment but by the judgment of MedPAC and other organizations and experts who study this. One Senator from Florida stood up and told me he agreed that payments to Medicare Advantage are excessive. Doesn't it make sense to take out the excess, the waste, and the fraud in order to extend the solvency of the trust fund? That is what this bill does.

It doesn't hurt seniors by ``cutting'' Medicare, leaving the implication that we are cutting Medicare benefits. It is an old saying in life: If you say something loud enough, maybe people will start to believe it. That is what the other side is engaging in.

If you look at the actual facts, the actuary says it does extend the life and solvency of the trust fund. The actual fact is we are cutting out waste. The actual fact is the industry has come to us and said: Help us with this, help us with that so we can be more efficient, much of what is going on here.

I have countless examples. Let me give a third one. This legislation would encourage hospitals and doctors to work together by bundling payments. If doctors and hospitals work together, guess what happens. They are less likely to order duplicate tests. They are working together. Payments based on fee for service, payments based today on volume, on quantity are, in some cases, wasteful. It is wasteful.

All of us who go to a hospital, a doctor's office, we kind of wonder: My gosh, some things seem wasteful here. We have to get new tests, new this; the doctor doesn't know what happened when I was here previously; we have to start all over again; new x rays, new imaging, so forth. They are waste. We

are trying to cut out a lot of this waste, and bundling payments is definitely going to help.

We have other techniques--accountable care organizations, medical home concepts. These could take 1 year, 2, 3, or 4 to kick in. But if they do work, it is the model of integrated care systems we all talked about which cut out waste and improve quality at the same time, and that is going to help Medicare. These integrated systems are going to also help extend the solvency of the trust fund and improve quality of care--not reduce it but improve it.

The main point I am making is these reforms will extend the life of the trust fund. And guess what. They improve the quality of care, not decrease the quality of care but improve it.

We also add some additional benefits for seniors that they will not receive if this legislation does not go into effect.

I note we only have a half hour on our side. I probably used more time than I should. The chairman of the HELP Committee is on the floor. Mr. President, how much time remains on the majority side?

I yield 10 minutes to the Senator from Iowa.

Will the Senator yield for a question?

If my colleagues will allow, I ask unanimous consent for 3 minutes.

I understand what the Senator is saying, and like everything around here, there is a kernel of truth in almost everything. I read that Samuelson article, and what I took away from it is the guy is kind of pessimistic. There is not a lot you can do. People love health care, they want to get all the health care they want, and that is going to drive up spending.

But the main point is this. You mentioned how Intermountain and the quality of care is so good at Intermountain and the costs are down.

I was going to say, it is Intermountain, and there are many other great integrated systems. There is one in Billings, MT--the Billings Clinic. There are lots of integrated systems, and generally in these areas, in these integrated systems--which I think work quite well--a lot of the doctors are salaried, a lot of the incentives are there to focus on health care of the patient, and it is coordinated care in contrast with some other parts of the country.

In this bill, in addition to wellness and prevention, I would ask if the Senator agrees the delivery system reforms will help move health care, as it is in Intermountain and other integrated systems, to encourage coordinated care, encourage bundling, encourage these accountable care organizations and so forth. I was wondering if the Senator thinks that will help systems--clinics, doctors, hospitals, nursing homes and health care providers generally--to work better together, where there may be more salaried physicians than there are currently, but the salaried physicians I talked to at the Mayo Clinic, for example, and Kaiser and other similar places, kind of like that because they get decent salaries and they can spend their time not on paperwork but can focus on the patients.

I am sure the Senator knows all the delivery reforms that are in this that help move toward the Intermountain direction, and I would ask if he thinks that will help.

One more moment, if I might, Mr. President.

I understand the bill that the Senator and Senator Wyden cosponsored is basically to move us away from the employer-based system. Currently, our tax law encourages employers providing tax free health insurance and so forth. I understand the theoretical and actual problems with the current system. In fact, I earlier advocated moving in that direction, all the way to your legislation. But as you know, this town, this city, this country, this White House was not moving there, and major business was not moving in that direction. Therefore, we had to find something else. My main point is, if we can't go in that direction--you might say keep trying, but read the tea leaves. If we can't do that, at least now, isn't it better to start moving toward the integrated delivery system reforms in this bill?

I hope so, too.

I like your answer, too. Thank you.

Mr. President, I am going to yield 10 minutes--this is a jump ball, so why don't you go ahead. I yield to the Senator from Vermont.

Will the Senator yield on that point?

Do we have any time remaining on our side, Mr. President?

I will take 2 minutes from our side to ask a question.

Correct.

May I ask the Senator from Wyoming a question? To, from, for--isn't the result the same? If we take a program--let's take home health care. We are all for home health care. But if there is fraud, if the GAO says there is fraud in home health--maybe others too--doesn't the Senator think it is a good idea that we eliminate some of the fraud that might exist in the Medicare Program? Does the Senator agree with that?

Does the Senator also agree that when that happens, that means that program--say, home health care, for example--is spending fewer dollars not on less care but fewer dollars because it is not making fraudulent payments?

Does the Senator further agree that would extend the life of the trust fund because that program--in this case, home health-- would be spending fewer dollars even though the quality of health care is not diminished? Doesn't that have the effect of extending the quality of health care, and isn't that reduction for Medicare, for seniors, not to take it away but to give it to seniors because it extends the life of the trust fund?

No, no, no. There is less spending; therefore, by definition, the solvency of the trust fund is extended, so there are more dollars for seniors in future years. That is the basic point here. That is not a dead end. That is a big wide avenue to help extend the solvency of the Medicare trust fund.

Madam President, I ask unanimous consent that the time until 1 p.m. today be under the same conditions and limitations as previously ordered; further, that the prohibition on amendments and motions also be extended until 1 p.m.

Madam President, I yield 25 minutes to the Senator from North Dakota.

Madam President, before we continue, I ask unanimous consent that the time be extended for debate only until 2 p.m., with the limitations of the previous order remaining in effect.

Madam President, I think everybody who is interested in the subject ought to read the CBO letter. Different people make different claims about the CBO letter, but I think it is only fair to read the entire letter, refer to the entire letter, not bits and pieces and parts of the CBO letter.

For example, it has been stated that CBO claims the average premiums--we are talking about the nongroup market. That is the individual market now. In fact, that is page 6 of their letter which said average premiums would be 27 percent to 30 percent higher because of greater coverage. That is the statement we just heard.

The CBO letter does say that. But I think it is also important to say that those people would be getting much higher quality insurance because of all the insurance market reforms we provide for in this legislation.

Even more important, CBO goes on to say on that same page in that same letter:

The majority of these enrollees, about 57 percent, would

receive subsidies via the new insurance exchanges, and those

subsidies on average would cover two-thirds of the total

premium.

It is true that some in the so-called nongroup market in the year 2016 would find their premiums go up without subsidies. I think that figure nets out to about 7 percent. But they are getting better insurance, much better insurance than they currently have because the insurance they buy in the exchange--we are talking about 2016-- will be much better insurance than they now have.

According to everybody else, a fair reading of the CBO letter leads one to conclude that premiums will basically go down by a little bit-- not a lot, a little bit--or be about the same. For example, I have heard on this floor the assertion, but no reference, no authority for this assertion--I heard this morning the assertion that for employees who work for larger companies, their premiums would go up. The fact is the CBO letter said just the opposite.

One can make the assertion premiums go up, but I think it is unfair to the American people to make rhetorical claims that are not backed up with authority. The CBO letter is probably the best authority we have for us to work with, and that letter says flatly that premiums for those persons--that is about five-sixths of Americans--would go down, not up, as has been asserted without the authority on the floor.

I am making the opposite assertion they will go down by about 3 percent. Not a lot but 3 percent. But my authority is the Congressional Budget Office. That is what they say.

Basically, 93 percent of premiums will either go down or be about the same. I mentioned a 3-percent reduction for the employees. Five-sixths of persons work for big companies and in the so-called small group market, CBO says--this is all the year 2016--premiums will be up 1 percent or down by 2 percentage points. It depends on who gets the credit. Some will, some will not.

Let's not forget small business gets credit under this legislation, too. I am not sure whether CBO calculated that in. A fair reading is the small group market, that is about 13 percent of Americans, it is, say, a net minus 1 because some go up 1 percent and some down by 2 percent.

Basically, if we compare apples to apples, that is what insurance will be in 2016--premiums will go down for those in the nongroup market, down by 14 or 20 percent. Because those with better benefits will find their premiums might go up by 10 to 13 percent and add in the tax credits which one has to do because that is the legislation, on a net basis, for two-thirds of those folks, their premiums will be lower by a large amount. By ``large,'' I mean by about 56 to 59 percent.

Who knows what is going to happen in 2016. CBO is giving their best shot based on this legislation. That is what their letter says. I have the letter right in front of me.

I might also say that CBO says--I don't know if it is in this letter or another letter--the bill is deficit neutral, and basically over 10 years--I think a 20-year period--the net effect is not much more government or less government, it is about the same as today. There are wild assertions: Oh, it is bigger government. CBO said government's involvement in people's lives will be basically no more or less than today, and that is partly because of a lot more choice people will have. They will have a lot more choice in the exchanges, a lot of choice under the exchanges. It is that choice which will encourage greater competition, and greater competition will encourage lower prices. At least that is the theory. Most of us tend to think competition lowers prices, and that is what the legislation does.

Unless the Senator from Wyoming wishes to speak, Senator Kerry, on our side, wishes to speak for at least 15 minutes.

Mr. President, I yield an additional 5 minutes to the Senator from Massachusetts.

Mr. President, how much time is remaining in this hour?

Mr. President, I would like to yield 3 minutes to the Senator from Massachusetts. I have spoken with Senator Sessions. He is very kindly and very graciously agreeing that Senator Shaheen from New Hampshire will be able to speak next after Senator Kerry. So Senator Kerry for 3 minutes, and then the remaining 5\1/2\ minutes will be for Senator Shaheen.

I also unanimous consent that we be able to proceed until 3 o'clock under the usual form; that is, under the conditions of the last agreement.

Mr. President, I yield 3 minutes to the Senator from Massachusetts. It is also my understanding that the Republican leader may come down at some point after Senator Shaheen speaks and use leader time. That is my understanding--or after Senator Kerry speaks. Whenever he comes, he comes. Thank you.

Madam President, I move to reconsider the vote, and I move to lay that motion on the table.

The motion to lay on the table was agreed to.

Amendment No. 2942

Madam President, the Gregg amendment is a killer amendment. It would kill the tax cuts in the bill, kill assistance for copays, kill the Medicaid expansion for the lowest income Americans, kill additional funding for the Children's Health Insurance Program.

Proponents advertise this amendment as protecting Medicare. That is false advertising. The Gregg amendment would kill health care reform. Health care reform would extend the life of the Medicare trust fund by 4 to 5 years. Health care reform would result in commonsense changes, such as decreasing hospital readmissions, decreasing hospital-acquired infections, and paying doctors and hospitals to work together. Health care reform will not reduce guaranteed Medicare benefits. Health care reform would extend the life of the Medicare trust fund.

The choice is clear. If you want to vote against tax cuts, Medicaid, and the Children's Health Insurance Program, vote for the Gregg amendment. If you want to extend the life of Medicare, vote against it.

Mr. President, for the benefit of all Senators, I want to take a moment to review today's program. This is the seventh day of debate on the health care reform bill. It has been nearly 2\1/2\ weeks since the majority leader moved to proceed to this bill. We have now considered 14 amendments, and we have conducted 10 rollcalls.

Between now and 3:15 this afternoon, the Senate will continue to debate the amendment by the Senator from Arkansas, Mrs. Lincoln, on insurance company executive compensation and, at the same time, we will debate the amendment by Senator Ensign limiting attorney's fees. The majority controls the first 60 minutes, and the Republicans will control the next 60 minutes. At 3:15 p.m., the Senate will conduct back-to-back votes on or in relation to the Lincoln amendment and the Ensign amendment.

Thereafter, we expect to turn to another Democratic first-degree amendment and another Republican first-degree amendment. That is the lineup at this time. It is possible the Senate may vote on those next two amendments today. As a result, additional votes are possible following the two votes at 3:15.

Once again, I thank all Senators for their cooperation and courtesy on this extraordinary weekend session.

Mr. President, I suggest that Senator Harkin be next recognized for 7 minutes.

Mr. President, I yield to the Senator from Connecticut all the remaining time, and if he wants to speak for a little longer, I know we can make some accommodations with the other side.

I ask unanimous consent for 1 additional minute.

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

Mr. President, how much time is remaining on our side?

Mr. President, I yield 9 minutes 39 seconds to my esteemed friend from Vermont.

Mr. President, how much time remains on this side?

A minute and a half. I yield 1 minute to my friend from California.

Mr. President, let me, in closing, remind Senators that the Senate is about to conduct two back-to-back votes. The first vote will be on the Lincoln amendment on executive compensation. The second vote will be on the Ensign amendment on attorney's fees.

Mr. President, I yield back the remaining time.

Mr. President, I ask for the yeas and nays.

Mr. President, I object.

Reserving the right to object, to be totally candid, these are stunt amendments which we have not seen. I have never heard of the amendments.

Reserving the right to object, because I have not even seen these amendments, I object.

Will the Senator yield for a question? Will the Senator yield for a question?

Yes.

Do the Senators realize and do they know that yesterday the Home Care and Hospice Association, the National Association for Home Care and Hospices, the umbrella organization for home health and hospice, wrote a letter to me, which basically says:

[F]or all of these reasons, we support the provisions of

your health care reform legislation as it relates to home

health care.

Is the Senator aware of that letter, the Home Care and Hospice Association's support for this legislation? Is the Senator aware of that letter?

This is not on my time because he is going to filibuster over there.

If the Senator will yield, with time being equally divided on both sides for this colloquy.

I can tell the Senator the deal. I am going to tell the Senator the deal.

I will tell the Senator what the deal was.

Will the Senator yield to know what the deal was?

Will the Senator yield for another question?

Does the Senator know that the so-called deal was that whereas MedPAC and the administration and the House wanted to make domestic cuts to home health care, but rather we went to the home health care industry, worked with them, and took two of their major suggestions about fraud and abuse as well as outliers, so we modified so that the home health industry thought this was fair and reasonable?

Does the Senator know that was the agreement that was reached?

Will the Senator yield? I can answer the Senator's question.

Mr. President, this is very frustrating because we have these blocks of time, with Senators lining up to take control of the time and to make their points, and then they flee the Senate floor and we cannot get into a debate or a colloquy. We cannot make points that rebut the points they have made because they have all left the floor.

They all come in and make their points and then they flee.

Good, I am glad they are staying because I want them to hear this. Maybe we will all learn something.

First of all, clearly, we all care about home health care. I mean, let's obviously agree that we all do. I see the Senator from Arizona nodding his head in agreement; he does care about home health care. This Senator cares about home health care. The Senator from Wyoming, Dr. Barrasso--here he is, over here--he cares about home health care. He has talked about home health care.

We all know seniors would rather be home than in the hospital or a nursing home, if that is medically appropriate. We all know that. I know that personally. My mother was in the hospital 2 weeks ago, and she is now, thankfully--praise the Lord--out of the hospital, and she is home. We have a home health care person coming in every day to see my mom.

When I am there with the home health care person, I am very impressed. They do a super job. It is really something to behold. My mother loves it and I love it. We clearly are not going to do anything to cut home health care.

But another point I would assume all my colleagues agree with is that we want to cut waste, if there is waste. We want to cut waste out of the health

care system. Why should we allow waste, as representatives of our people--the taxpayers? We want to cut out waste. Again, I see the Senator from Arizona is nodding his head, yes, that clearly we want to cut out waste that may or may not occur in the system.

Now, the next question--and it is a question--is, there are lots of forms of waste, and one is fraud--people just ripping taxpayers off and ripping seniors off. That is clear. There is a lot of waste. Let me take one small example in the home health provisions in the Senate bill, and that is this: The General Accountability Office found that in the home health industry there are a lot of outlier expenditures which are fraudulent; that is, some home health agencies classify their expenditures for home health as outliers--as extra payments--for very sick people.

In fact, there is one county in Florida which accounts for 60 percent of all outlier reimbursements, whereas they provide health care for only 1 percent of the Nation's people. The GAO has found lots of examples where the outlier portion of home health is abused. It is fraud. It is abused. Well, guess what. The home health care industry came to us and said: Gee, we have some ideas how to stop that because we don't like rotten apples spoiling our barrel. We want to stop this fraud that exists with excessive outlier payments.

So they came to us with some ideas. I know it is easy to think that suggestions might be classified as deals or whatnot, but that has not happened. They came with an idea of how to cut excessive costs in outliers, and we have done that. That is in this bill. There are a lot of other provisions with respect to home health care.

I know the Senators have letters from their home States. I don't know if they are referring to a House-passed bill, which is very aggressive in cutting home health care benefits, or whether they have read the most recent language in the Senate bill, which essentially is much less aggressive because in talking to the agencies, they were saying: Yes, we can live with these changes--such as rebasing and market basket updates, phasing them in instead of immediately--with the idea, again, of getting rid of excessive payments and fraudulent payments.

I say excessive because the home health care industry is enjoying an 11-percent growth rate annually, as it is right now in dollars. Well, some think it is 17 percent. The chart I have is 11 percent, but maybe 17 percent. Then the national health care spending rate, spending for all care, goes up about 6 percent a year, about 6 percent a year nationwide. Home health without reform is between 11 and 17 percent. It is almost double.

Under this legislation spending will be about 8 percent. Remember, national health spending is 6 percent, and the home health industry did write a letter saying: Yes, we can live with that.

My approach, frankly, in regard to legislation, is to work with groups, to work with industries and talk to them and not just be draconian and not be arbitrary in cuts or changes. You talk to them to see what accommodations can be made consistent with your principles.

One of my principles is stopping a lot of the fraud and to see if there is a way to cut excessive spending because sometimes there is excessive spending around here, and that is what we have done in the home health industry.

I could go into more detail, but I want my colleagues to know there is real, solid, sound reason for these changes in the home health provisions, and it is my judgment this will not hurt home health care for patients. That is a very important point to make.

The same is basically true with the other industries--say with regard to the hospital industry. We worked with them and said: OK, we know you should be cut. I talked to a lot of hospital administrators privately and said: What do you think?

They said: Yeah, Max, we should take a haircut. Our hospital should take a haircut.

As you well know, you sometimes go to a hospital and you say: Good gosh, why do they have that big fountain out front? Why do they have all that marble? Why does this look like the Taj Mahal? You don't need that for health care.

So then they crank that back for the need of their health care. Some of the executives say to me privately: Yeah, there should be some reductions in hospital payments. So we go to the hospitals and say: What is reasonable? Remember, this is over a 10-year period.

They say: We could take a $155 billion cut. But they say that, in part, because they know what they lose on the margin they can make up in volume because of everybody's health insurance. That means, too, that we can get health care reform.

You know, it is hard to get the health insurance industry to work with us if there is no health insurance for most Americans. If there is no health insurance for most Americans, then the health insurance industry is inclined to revert back to their old ways--or try to anyway--underwriting insurance, denying policies based on preexisting conditions, et cetera.

So this whole effort is to work with groups--work with consumer groups, with labor, with hospitals, doctors, the insurance industry, pharmaceuticals--to see what is reasonable. That is democracy--to try to get some kind of broad-based kind of rough justice agreement to put this together. That is the effort we have undertaken in this legislation.

I hear criticism, well, gee, we are cutting this and cutting that. But let's remember--and I know my colleagues agree with this--the waste in the American health care system is somewhere between $300 billion a year to upper estimates of $800 billion a year. It is waste, and we have to figure out a way to get rid of the waste without sacrificing care and actually, at the same time, improving the quality of care. That is the major goal.

So when you see reductions in some of the payments to providers, a lot of that is an honest attempt to get rid of the waste or excessive payments. Let's take Medicare Advantage. Somebody quoted Tom Scully today. I have a quote from Tom Scully that says there is way too much spending in Medicare Advantage. I don't have the exact quote, but it is basically a public quote that we should cut Medicare Advantage spending because there is way too much expense in Medicare Advantage.

It is a question of judgment as to how much to cut, I grant you. But still there are areas where there is excessive spending, there is waste, and home health care is a good area where we worked hard to refine the changes to get rid of some of the fraud--the outliers I mentioned--but in a way that helps seniors get good home health care.

I agree, so long as it comes off their future time.

Mr. President, I would very much like to respond to that question. First of all, I appreciate the implied premise in the statement that the Senator agrees there should be savings.

The question is, Where should the savings go? I mean, basically, the Senator is implying there should be savings, and that is very good to hear. I think that is a very constructive addition to a part of this dialogue, this conversation, that we should take savings because there is waste.

The Senator's question is, OK, you take the savings, what should we do with the savings? That is the basic question.

The fact is, because of the reforms in Medicare, a couple things are happening. No. 1, we are extending the solvency of the trust fund; it is another 5 years. The Medicare trust fund will now be extended 5 years, so that helps seniors.

I know the Senator didn't mean this at all, but, rhetorically, earlier he said: Why does this side want to throw seniors under the bus? I know he didn't mean that. I know he knows nobody is trying to throw seniors under the bus, nobody wants to do that in the Senate. But the fact is, these changes do extend the solvency of the trust fund.

Then he asked a different question, and it is a very good question. It is a judgment call, what should be done with the additional savings? This legislation takes those savings to help more people get health insurance. One could argue those savings should not be used to help those without health insurance get health insurance for them. They could go back to the Medicare trust fund, they could reduce the budget deficits--there are a lot of different options here. But this is a health care reform bill. In this legislation, we are trying to come up with a system, if you will, that gets some coherence nationwide in health care. We don't have a system today. It is a hodgepodge. It is a collection. It is kind of a free-for-all. Docs do their things, hospitals do their things, nursing homes do their things; each attempt to get health care based on profit motive, but it is kind of incoherent. There is no real--anything there.

We say let's try to look for coherence. We are the only industrialized country in the world that does not have some system, some way where everybody has health insurance. It seems to me we should try to see if we can have some kind of system, some way, where everybody has health insurance. I know it is extremely complicated. There is no doubt it is complicated. But if people have health insurance, that opens up lot of doors for other reform; one is to prevent companies, health insurance companies, from denying coverage based on preexisting conditions, health care status, and so on and so forth, because then what they lose on the margin, they can make up in volume because everybody has health insurance. It is the same with the hospitals, same with the pharmaceutical industry, same with virtually all providers, the whole system. If everybody has health insurance, not most everybody--more have health insurance the better the system is.

That is a judgment call. But I do believe, when people have health insurance--those who do not now have it--are going to be more healthy. I think that is a good thing. Hospitals will not have to worry near as much about uncompensated care, which is a big challenge to hospitals these days. The average, I think, is about $1,100, $1,200 a year per family, when it comes to uncompensated care that private patients' pay. Then, after that, we open up doors to delivery system reform. You get the system working a lot better, compensating more on quality outcomes rather than quantity, et cetera. I know the Senator knows much about all these things.

But it is a judgment call for those savings. I am glad the Senator seems to imply there should be or are savings, but it is a judgment call as to where the savings go.

The 21 percent in docs, we are going to have to take that up after this bill. It is going to be difficult because some want to pay for it; some want to not pay for it. I grant you, that is going to be a huge battle.

You might ask: Why is that not in this bill?

My answer to that is, A, it is not part of health reform. But, B, on the other hand, it is; they are docs, we care about our docs and we are going to have to find a way to pay for them and we will, I think, by the end of this year because we have to. Docs--there cannot be any reduction.

Frankly, there is a partial fix in this bill anyway. It is 1 year with an update. At least this bill does take care of docs for at least 1 year and with an increase. That is 1 year. The House wants a permanent fix.

Frankly, I would love to have a permanent fix, but we are having a hard time finding the dollars to pay for it all, but this legislation does have a 1-year fix for docs.

I yield to the Senator from Massachusetts.

If the Senator will yield, I thank my colleagues for staying on the floor. I appreciate that.

It will have to be on your time.

Mr. President, I think we have less than 4 minutes remaining on this side. I see someone else who wishes to speak. I promised him time, and Senator Durbin as well. I know they are both eloquent orators. It is a bit difficult here. So I will split it in half, the time remaining, between each of the two.

Fine.

Thank you.

Madam President, I ask unanimous consent that we continue with debate, and debate only, as under the previous order, for an additional hour, with Senators permitted to speak for up to 10 minutes each.

Madam President, I yield to the Senator from Michigan, Ms. Stabenow, 5 minutes.

I yield 1 minute.

Madam President, I ask unanimous consent that Senator Rockefeller be added as cosponsor to the Lincoln amendment, No. 2905.

Madam President, may I ask how much time remains on each side?

I thank the Chair. I yield 10 minutes to the Senator from Illinois.

Madam President, I suggest the Senator from Iowa be recognized.

Madam President, I ask unanimous consent that 10 more minutes of debate be allowed, evenly divided.

Hearing no objection?

Madam President, I would just like to state as clearly as I possibly can, so people understand, the Medicare savings are being used for Medicare. There is a strong implication by many Senators that the savings are not going to be used for Medicare, that it will go someplace else. That is not true. The Medicare savings are going to be used for Medicare.

What are the savings? I think all Senators would like to reduce waste. All Senators agree there is too much waste in the current system. It makes good sense to try to attack that waste, root out that waste, and where there are overexpenditures, to try to get the levels down to a reasonable level. Everybody knows we have spent too many dollars on Medicare Advantage. Everybody knows that. That is why we are bringing that cost down.

There is also waste and fraud--I know my good friend from South Dakota understands this--in home health care agencies. In the State of Florida, for example, the Government Accountability Office showed that in Florida 60 percent of the outlier payments--the extra money that goes for sicker patients--were in one county. That county has 1 percent of seniors. It had 60 percent of the outlier payments, according to the Government Accountability Office. That is fraud. They rooted out a lot of fraud in home health.

Home health is very good. My mother is in home health right now. It works really well. I am very proud of the home health caretaker there who takes care of my mother. But we are reducing some of the overpayments. We are getting the waste out. And guess what. Those savings, where do they go? They go back into Medicare. I repeat that. They go back into Medicare. I do not know if any Senator wants to open up his ears or her ears and hear that. They go back into Medicare. Guess what. That is why the solvency of the Medicare trust fund is extended.

If these so-called cuts, which we hear about on the other side, were really cuts, as implied by the other side, you would think that would hurt Medicare. You would think that might reduce the period in which the trust fund would be solvent; that it would go insolvent at an earlier time, if we were really cutting Medicare. No, it is the opposite. These are savings in Medicare which extend the life of Medicare.

Please, please--I see my friend from Iowa. I think he understands, these Medicare savings go into Medicare for extending the solvency of the Medicare trust fund. I see my friend from South Dakota. I think he understands--he is sitting there and grinning at me now--

I think he understands those savings go back into Medicare and extend the solvency of the trust fund. So let's make that very clear.

Second, we are using some of the money to reduce Part B premiums. That helps seniors. If Part B premiums are reduced, that helps seniors. By how much? Madam President, $30 billion over 10 years. That will reduce seniors' Part B premiums. That helps seniors. We are not taking money away from seniors; we are helping seniors, giving more dollars to seniors in this legislation.

In addition, there are additional benefits for seniors in this legislation. We are starting to close the doughnut hole--that is something seniors talk about--in prescription drug benefits. They want that doughnut hole closed.

I might add to that, there are other benefits: new preventive benefits under Medicare for mammograms, preventive screenings, colonoscopies, annual wellness visits--all new benefits.

So I want to make it very clear that it is not true when some Senators say we are taking money away from Medicare and creating a whole new entitlement program. We are not taking money away from Medicare and hurting seniors. We are reforming how dollars are paid, taking the waste out, and extra, excessive payments, and putting the money back into Medicare, back for seniors, back for beneficiaries.

Also, not one penny of guaranteed benefits will be cut. Not one penny can be cut. So please, people, understand that the savings go to help seniors, with more benefits, extending the solvency of the trust fund. That is what we are doing. If we keep that firm point in mind, then maybe we can go address some of the next steps that are in this bill. But that is very important.

Madam President, I do not know how much time I have.

Madam President, he can probably extend a little bit. I see the Senator from Minnesota anxiously sitting over there in the corner. Maybe we could give him a couple----

Madam President, I suggest the absence of a quorum.

As long as it is equally divided between the two sides.

Madam President, if my good friend would allow me to interrupt to propound a unanimous consent agreement so Senators know when votes are going to come up, and then continue.

Madam President, I ask unanimous consent that once this agreement is entered, it be in order for Senator Kerry or his designee to be recognized to offer the majority side-by-side to the Johanns motion; that the Senate proceed to vote in relation to the Kerry amendment; and that upon disposition of the Kerry amendment, the Senate then proceed to vote in relation to the Johanns motion; that no amendments be in order to the Kerry amendment or the Johanns motion; further, that upon disposition of the above-referenced amendment and motion, the Republican leader's designee be recognized to call up an amendment related to the Lincoln amendment No. 2905; further, that on Sunday, December 6, after the Senate has resumed consideration of H.R. 3590, the time until 3:15 p.m. be for debate with respect to the Lincoln amendment No. 2905, and the Republican amendment identified above; with the time on Sunday equally divided and controlled, with Senators permitted to speak for up to 10 minutes each; that at 3:15 p.m., the Senate proceed to vote in relation to the Lincoln amendment No. 2905; that upon disposition of amendment No. 2905, the Senate then proceed to vote in relation to the Republican amendment related to the Lincoln amendment; that all of the amendments and motions covered in this agreement be subject to an affirmative 60-vote threshold and that if any achieve it, then they be agreed to and the motion to reconsider be laid upon the table; that if they do not achieve that threshold, then they be withdrawn; that prior to the second votes covered in this agreement, there be 2 minutes of debate; that after the first vote, each succeeding vote covered here be limited to 10 minutes each; provided further that no other motion be in order, except a motion to reconsider a vote with respect to the above-referenced amendments and motion.

Madam President, I might say, that is our understanding on this side as well.

Amendment No. 2926 to Amendment No. 2786

Madam President, I call up the Kerry amendment which is at the desk and ask for the yeas and nays.

Madam President, this is very simple. A vote for the Johanns amendment is a vote for the status quo. What does that mean? It means seniors will continue to pay higher and higher premiums, higher cost sharing due to wasteful overpayments. A vote against Johanns means we can extend the solvency of the Medicare trust fund that helps benefits.

I think we are for seniors in this body. I urge a vote against Johanns.

Mr. President, we are beginning our fifth day of consideration on the health reform bill. We will be in a period of debate only until about 11:30 a.m. Pending now is the

amendment by the Senator from Rhode Island, Mr. Whitehouse, on fiscal responsibility. Also pending is a motion to commit by the Senator from Utah on Medicare Advantage. It would be my hope that the Senate will vote on these matters today.

Mr. President, I suggest the absence of a quorum.

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

Mr. President, experts and economists of every political stripe agree that preserving America's long-term economic security means reforming the way we provide and pay for health care. Health care spending makes up one-sixth of the U.S. economy. Future generations can expect the burden of insurmountable debt if we fail to act.

The fiscal challenges we may face in years to come pale in comparison to the threat of uncontrolled Federal health care spending. The chart behind me essentially shows that. The chart shows the percentage annual growth rates beginning in 2004. The red is the economy, the blue is health care costs. Clearly, over time, especially as the economy dipped during this great recession, the gap between economic growth and health care spending has widened. Projections are that in future years they will widen more and more. As you can see out to 2018, the total economy is projected. Near 2018 the economy is above 4 percent and health care spending is 7 or 8 percent.

Doing nothing means health care spending continues to grow faster than our economy. That is what that chart shows quite dramatically. Doing nothing means entitlement spending more than doubles by the year 2050. That is taking one-fifth of our gross domestic product.

But it is not simply the Federal budget on the line, it is the family budget too. Incredibly, in total we are spending 80 times as much on health care today as we did five decades ago--80 times more on health care today than we did five decades ago. Now family budgets are breaking under the strain--already. That is going to get worse if we do nothing. The cost of the average family health care plan will reach $24,000 in the year 2016. That is not too many years away from now. This represents an 84-percent increase over 2008 premium levels. That means, if we do nothing, in fewer than 10 years most families would have to dedicate half of their household budget to health insurance. For years we have heard the warnings from Federal budget experts. Now we are hearing every day from folks back home who simply cannot afford the care they need.

We have an obligation to act. Now we have an opportunity to act. The country's leading economists and Federal budget experts laid out strategies and options for getting costs under control. We have taken their recommendations to heart. There is a lot of agreement among those who study these issues of what we must do. Now we have a bill that does what they suggest. It also passes the test of fiscal responsibility.

We have many reasons to vote for this bill. It protects and even increases Medicare benefits for seniors. It achieves near universal coverage in less than 10 years. That means it achieves the goal of virtually everybody having health insurance in that period of time. It slows the growth of Federal health care spending. It stops insurance industry discrimination and, based on independent, nonpartisan analysis, makes a serious dent in our Federal deficit.

This chart behind me represents what 2 weeks ago the Congressional Budget Office and Joint Committee on Taxation confirmed in no uncertain terms, that deficits go down under this plan. The official cost estimate reads as follows:

The Congressional Budget Office and the Joint Committee on

Tax estimates that on balance the direct spending and revenue

effects of enacting this Patient Protection and Affordable

Care Act legislation would yield a net reduction in Federal

deficits of $130 billion over the years 2010 to 2019. That is

represented by the green bar on the left. It is a net $130

billion reduction during the first 10 years of this bill.

In addition to reducing the Federal deficit, in the first decade, the CBO also tells us that the bill decreases the deficit by a much greater amount, by $650 billion, in the second decade.

According to the CBO, this bill also slows the growth of Medicare costs, which has been a principal goal in our Medicare debate since day one. Medicare spending would grow 6 percent annually instead of 8 percent annually. In other words, Medicare would continue to grow but, unlike today, it will grow at a sustainable rate.

Of course, no projections, even from the Congressional Budget Office, can be certain. We can safely say this bill will put us on the right track. We can safely say this bill is better than doing nothing. No honest assessment challenges the case for acting now to slow the growth of Federal spending. No honest assessment challenges the case. And no honest assessment of this bill challenges the CBO analysis. I have not heard one. I have not heard an honest challenge to the CBO analysis, nor have I heard of a good, honest case for not acting now to slow the growth of Federal spending, which means we have many reasons to pass health care reform, not the least of which is the long-term financial health of the economy and our Nation. But the reasons for passing this are much more than simply facts and figures. This is about Americans from every corner of this great country, struggling to make ends meet, forced into bankruptcy by medical tragedy. This is about stopping insurance industry discrimination; this is about saving Medicare for our seniors and reducing the deficit for our grandchildren.

I don't know which other Senators wish to speak. Senator Bingaman wishes to gain recognition in the time we have.

Let me ascertain how much time we have and how many speakers we have.

I yield 15 minutes to the Senator from New Mexico.

Mr. President, how much time remains under the control of the majority?

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

We might be able to find extra time, too, if the Senator is looking for extra time. Right now, according to the number of Senators who

want to speak, that is all we have in this first block. But sometimes we can work things out--if the Senator wants to talk a little longer. But right now it is 10 minutes.

Mr. President, I yield 8 minutes to the Senator from Wisconsin, the chairman of the Special Committee on Aging.

Mr. President, how much time remains for the majority?

I ask unanimous consent that there be an additional 5 minutes on each side.

Mr. President, I yield the remaining time to the Senator from Oregon, which should be 10 minutes.

Mr. President, how much time is remaining on the majority side?

And on the minority side?

Mr. President, I reserve the remainder of the majority time.

Mr. President, if I may, I ask unanimous consent that we extend for an additional hour the period for debate only with no further amendments or motions in order during the hour; and that the time be equally divided between the two sides, with the Republicans controlling the first 30 minutes and the majority controlling the second 30 minutes.

I believe there is 3 minutes remaining on the first block, on the majority side?

Mr. President, I think I will use my 2 minutes 20 seconds.

OK. I want to make three basic points. The Senator from Arizona talks about, gee, all these Medicare Advantage plans have dental and vision coverage. He goes on to say, so do Members of Congress.

The fact is that is not automatically true. The fact is Members of Congress choose among various private plans. Some plans offer dental and vision, some do not. Aetna is a company that Members of Congress could choose from under FEHBP and others that Members of Congress can choose from. Those do provide dental and vision coverage. But there are others--I think Blue Cross and Blue Shield does not provide dental and vision coverage.

I make that point because this is exactly what we are trying to set up in these exchanges. People could participate in the exchanges, where they would buy private coverage and they could choose among various private plans which coverage they want. Do they want a plan that covers dental and vision, or not? That is exactly what we are trying to do in the exchange, as is the case for Members of Congress. Medicare Advantage plans do provide dental and vision. I think that is great.

I see my time has expired. At the appropriate time I wish to go into greater detail and explain why what we do in this bill I think makes eminent sense.

Mr. President, I understand we are now under the order where there is a half hour allocated to the majority side; is that correct?

Mr. President, I yield myself 10 minutes.

Mr. President, I just want to help people understand this legislation. I am sure many do, but I am sure there are some who do not with respect to the choices people will have.

We have a uniquely American system of health care in America. It is roughly half public, half private. The goal of this legislation is to retain what we have; that is, basically have that same balance of public and private. It has worked pretty well for America. It is uniquely American. We are not Canada. We are not Great Britain. We are not Switzerland. We are the United States of America. I think it is good to build on our current system and make our current system work better.

I am prompted to explain the choices, in part by the statements by the senior Senator from Arizona, who said Medicare Advantage plans enable people to get eyeglasses and dental care. And that is true. But he went on to say that, gee, shouldn't Members of Congress, who like all that and want to keep all that--that Members of Congress get free dental and free eyeglasses. Well, that is really not true. Members of Congress do not get that. But it is true Members of Congress participate in--all Federal employees, Members of Congress, people in the Forest Service, people all around the country--all Federal employees participate in the same system. It is called FEHBP. It is the Federal Employees Health Benefits Plan, where Federal employees and Members of Congress, all together, the same, can choose among many different private health insurance plans. There is an open enrollment season--in fact, we are in the midst of it right now--where Members of Congress and all Federal employees can look to see if they want to choose a different insurance company or not. Some of those companies do provide dental and vision coverage. Some do not. So if a Federal employee wants to choose a plan that covers dental and vision, he or she can do so. Just pay the premium, and you are covered with dental and vision.

We are setting up under this legislation an exchange that is very similar--almost identical--to the FEHBP, where people who do not have health insurance can go look on the exchange and choose, among private companies, which one makes the most sense for them. Some may have dental, some may have eyeglass coverage, some may not. That is just a choice people can make.

In addition to that, there is even more choice, because currently a Federal employee does not have to join FEHBP. A Federal employee can choose not to get health insurance if he or she does not want to or maybe they get it through their spouse someplace else. The same can be true with the exchange set up in this legislation. The person could buy among different competing private plans that offer health insurance on the exchange or a person can go outside the exchange because he or she thinks they can get a better deal, if that person wants to.

So I just want to make it clear that we are encouraging choice. We are encouraging competition. And I might say that under the legislation, Members of Congress who fully participate in this will be coequal with others. If there is a private option, Members of Congress can participate in that as well. In fact, we are requiring Senators and their staffs--they do not have to participate in the exchange, but it is certainly available to them, and they can opt out if they want to.

Let me just say a little bit about Medicare Advantage. What does MedPAC say about Medicare Advantage? Several years ago, Congress established an advisory board that is now called MedPAC to advise them on how Medicare should pay providers in traditional fee for service and private health insurers in Medicare Advantage. Again, Medicare Advantage is with private companies. They have executives. They have stockholders. They are private companies. MedPAC advises us how much Congress should pay MedPAC and other Medicare providers in traditional fee for service. It is an independent agency. Its experts are nonpartisan, highly respected.

Each year, they send a report to Congress that examines issues in Medicare. Here is what MedPAC had to say about the current state of Medicare Advantage in its 2009 June report. I am going to quote now from this independent advisory panel:

First, we estimate that in 2009 Medicare pays about $12

billion more for enrollees in Medicare Advantage plans than

it would if it were fee-for-service Medicare.

Second:

Current high payments have resulted in some plans that

bring no innovation but simply mimic fee-for-service Medicare

at a much higher cost to the program.

In other words, they are saying that Medicare Advantage plans get paid for a lot more but with no innovation compared to the fee-for- service Medicare.

MedPAC says:

This situation is unfair to taxpayers and beneficiaries not

enrolled in Medicare Advantage who subsidize the higher

costs.

Well, that is pretty obvious.

In addition, MedPAC goes on to say:

The excessive payments encourage inefficient plans to enter

the program, further raising costs to Medicare.

There are so many dollars currently given to Medicare Advantage plans, according to MedPAC, that encourages inefficient plans to enter the program. Why not? They are getting all of this extra money.

Further quoting:

The cost of Medicare Advantage subsidies is borne by

taxpayers who finance the Medicare program and by all

Medicare beneficiaries via Part B premiums.

Or to say it differently, about 78 percent of Americans who are not in Medicare Advantage plans are paying, in effect, a $90-per-year tax for which they get no benefit which goes into the Medicare Advantage plans.

In addition:

The Part B premium for all beneficiaries is increased by

about $3 a month, regardless of whether you receive the

benefit.

A couple of more quotes from MedPAC:

The additional Medicare Advantage payments hasten the

insolvency of the Medicare Part A trust fund by 18 months.

That is an interesting statement. The additional payments hasten the insolvency of the Medicare Part A trust fund by 18 months.

Going with quotes from MedPAC:

Although many plans are available, only some are of high

quality.

In addition, continuing the quote:

Only about half of the beneficiaries nationwide have access

to a plan that CMS rates as above average in overall plan

quality.

This is what MedPAC says. That is the nonpartisan expert that helps advise Congress on what reimbursement levels should be.

We have heard day after day that this bill is cutting Medicare benefits for our seniors. When my colleagues on the other side of the aisle realized this bill does not cut, reduce, ration, or eliminate a single guaranteed benefit, they turned their argument to Medicare Advantage. I think they finally recognize there are no guaranteed benefits cut in this legislation, so they turn to Medicare Advantage. They argue that the efficiencies and savings achieved by ending billions of dollars of overpayments to these private plans will either end the program or dramatically cut services to beneficiaries.

But let's just look at the numbers. I have a chart behind me. This chart shows the yearly spending for Medicare Advantage in billions of dollars. So you can see from the chart that in the year 2009, $110 billion will be spent on Medicare Advantage plans. That is the far left. Moving to the right, 10 years later, in the year 2019, about $204 billion is spent. So if we total it all up, about $1.7 trillion will be spent on Medicare Advantage plans over the next 10 years.

You see that little--what color is that? It is kind of orange, it is kind of an interesting sort of red--whatever it is, at the top of that chart. That represents the reduction in Medicare Advantage plan payments under this legislation. It is not very much, as you can tell by looking at the chart. It averages out, I think, to around a 10- percent reduction in Medicare Advantage payments.

So when we see these big crocodile tears, and we hear Medicare Advantage is being cut; when we hear all of these dramatic statements that so much is going to be taken away from seniors because Congress is cutting Medicare Advantage, the fact is, we are reducing the rate of increase in Medicare Advantage payments by only about 10 percent, and under this legislation about $1.7 trillion will be spent on Medicare Advantage plans. Remember, MedPAC says these are overpayments. MedPAC says this 10 percent reduction is what they should be paid.

Remember, too, these are private plans. These are private companies. It is not Medicare. These are private companies receiving these payments, and they are insurance companies. It is interesting to me that a lot of Members of Congress aren't too wild about insurance companies. Well, Medicare Advantage companies are insurance companies. That is what they are. They are private insurance companies. They are private insurance companies. They have their private insurance company chief executive. They have their private insurance company officer. They have their private insurance company stockholders. They have their private insurance company administrative costs and marketing expenses. They are private insurance companies. That is what they are. So we should not lose sight of all of that.

I wish to also point out that as private insurance companies, these Medicare Advantage plans are doing pretty well. Let me quote from an Oppenheimer Capital analyst in a November 12 report about Medicare Advantage plans. He said:

Between 2006 and 2009, we estimate that Medicare Advantage

accounted for nearly 75 percent of the increase in gross

profits among the larger plans in the industry, highlighted

by an estimated gross profit increase of $1.9 billion in

2009, relative to commercial risk earnings gains of nearly

$600 million.

Commercial risk earnings gains are the ordinary health insurance companies, but 75 percent of the gross profit increase was under Medicare Advantage plans, not traditional health insurance.

I might say, too--I don't have the papers; maybe I can find them. It is worth noting, it underlines the point that these are private companies. It is not traditional Medicare.

Here it is. Because it is interesting, let's look at the compensation of these insurance company executives of these Medicare Advantage plans, the CEOs. The total compensation of a CEO at Aetna is $24 million a year. The total compensation of the CEO at Coventry is $9 million a year; at Wellcare, $8 million; at Humana, $4.7 million a year; and at United Health Care, $3 million. Now, people should be able to make some money and officers of companies should be able to do OK, but here we are talking about very high salaries that these insurance companies pay to their top executives. Frankly, if there is a 10- percent reduction in the $1.7 trillion over 10 years, they could, you would think, take some of that 10 percent maybe in salary reduction or dividends to stockholders, make other cost savings. It doesn't have to come out of the beneficiaries. It is they, the executives, who are making these decisions of where the 10-percent reduction is allocated.

Bottom line, I just wish to say I am not opposed to Medicare Advantage plans. Frankly, I think it is good we have Medicare Advantage plans. Medicare Advantage plans provide the competition to Medicare. They help keep the system on its toes. But we have an obligation as Members of this Senate to the taxpayers and to seniors to cut waste and to cut overpayments in a way that does not harm beneficiaries. These are reductions recommended to Congress by the best advisory board of experts we could find. They didn't just come out of thin air and Members of Congress thought this up. This was recommended to us by the MedPAC advisory board.

Second, there is no reduction in guaranteed benefits to seniors. That is absolute. There is no reduction in guaranteed benefits to Medicare Advantage participants. So A, we are being fair. This chart shows it. We are trying to find the right level of reimbursement set up in a way so there is no reduction in beneficiaries' benefits. In fact, in this legislation, we add more benefits for Medicare participants, Medicare Advantage, as well as traditional fee-for-service Medicare. I might add in this legislation we give an increase to Medicare Advantage plans that show demonstrated improvement in quality.

As I mentioned, MedPAC said a lot of these plans are totally inefficient. A lot of these plans have no coordinated care. A lot of these plans don't have any quality, but they get the extra money. So we are saying let's get to a compensation level that is fair. We do it on a competitive bidding basis, take the average bid for an area, and we also say let's make sure there is no reduction in guaranteed benefits at the same time. I think that is a responsible thing to do.

So all of these arguments, these sound bites, frankly, that you hear from the other side of the aisle are just that, they are sound bites. They are not the honest analysis of what is going on.

So I encourage us to keep in mind, keep in perspective what we are doing so we can help provide a better health care system for our country. This is only one part of it. There are many other parts, but this is just this one part.

How much time do we have remaining, Mr. President?

I see Senator Dodd is on the floor. At this time I yield to the Senator from Michigan.

Mr. President, we are playing things by ear. I ask unanimous consent that the Senator from Wyoming be recognized to speak for debate only, and at a later point, we will figure out allocation of time on both sides, if he wishes to speak now.

I might modify that so this side gets the next 30 minutes after that.

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

Mr. President, the pending motion would strike the savings the bill achieves from Medicare Advantage.

Why are we seeking savings from Medicare Advantage? Because MedPAC tells us that the government pays the private insurance companies that provide Medicare Advantage 14 percent more than we pay traditional Medicare; because these extra subsidies to Medicare Advantage cost the four-fifths of seniors in traditional Medicare $90 more a year in premiums even though they get no benefits from Medicare Advantage; because MedPAC says that ``the additional Medicare Advantage payments hasten the insolvency of the Medicare Part A trust fund by 18 months; because the private insurance companies that provide Medicare Advantage are making three-quarters of their profits from these government overpayments, and they can find some of the savings there; because private insurance companies that provide Medicare Advantage are paying their CEOs $24 million, $9 million, and $8 million a year, and they could find some of the savings there; and because nothing we do in our bill reduces benefits under Medicare.

Therefore, I urge my colleagues to oppose the motion.

Mr. President, I move to reconsider the vote.

Mr. President, the Senator from Arkansas is to be recognized to offer an amendment.

Amendment No. 2905 to Amendment No. 2786

I yield Senator Klobuchar 10 minutes.

Mr. President, I think we are going to go back and forth here.

Sorry?

Well, we are going to go back and forth. Here is Senator Kaufman.

Back and forth, and forth and forth, and to and fro, and this and that it works fine for me.

Mr. President, I have heard a lot here today about how this is going to hurt seniors and so on and so forth, words such as ``smokescreen.'' The fact is there is no smokescreen here whatsoever. This is a very well thought out, considered policy that I think strikes a very good balance between getting care to especially seniors at home, which is so important on the one hand, and making sure there is not waste on the other hand. That is our responsibility here, to make sure the program works and works well.

I have sort of a special interest in this. My mother was in the hospital. It happened about 2 weeks ago. She fortunately is doing much better. She is out of the hospital. She has spent some time with a home health caregiver with whom I was very, very impressed. This home health person is doing a great job with my mother. I have seen other instances too, but personally I was very happy to see my mother getting very good care from a home health care nurse.

I think it is also important to remind my colleagues that this amendment is generally a retread on the McCain amendment we debated over the last few days. That is, once again, the opponents of this bill are endorsing the status quo that leaves Medicare on the brink of going bankrupt and seniors facing higher costs.

Let me remind my colleagues again what will happen if we stick with the status quo. The status quo, meaning no bill, which the other side is advocating, means Medicare will go broke in 8 years. That is the status quo. In our legislation, that will be postponed for at least 5 more years. The status quo, as in no bill, which the other side is advocating, means seniors will continue to pay higher and higher premiums and cost sharing due to wasteful overpayments to health care providers.

There is so much waste in our system. We all know there is a lot of

waste. I am quite surprised not all of our colleagues want to cut out the waste. In effect, they want to keep the waste that, unfortunately, is in our system.

The status quo also means each year billions of Medicare dollars will continue to be wasted on lining the pockets of private insurance companies. That might be a bit of a strong statement, but the fact is, some chief executives of private insurance companies are paid tens of millions of dollars to manage Medicare Programs, especially Medicare Advantage, and the status quo means that will continue.

The status quo also means seniors will continue struggling to pay for prescription drugs. The stakes for seniors in the Medicare Program have never been higher.

We have a choice. It is a very simple choice: either endorse the status quo or strengthen Medicare.

Let's talk a little bit about home health care. Regarding Medicare changes for home health providers, let me describe what is in the Senate bill. I don't think our colleagues know specifically what is in the Senate bill. That may be a strong statement to make. But if they knew what was in the bill, I think some of the statements made tonight might be a little bit different.

As most of my colleagues would agree, home health care is an extremely important benefit in the Medicare Program. We are all very strong advocates of home health care. Across the country, there are more than 9,800 home health agencies providing care to seniors in their homes. This helps seniors get better and helps them to avoid expensive rehospitalizations.

We are all champions of home health care. We would like people not to be institutionalized. It is much more appropriate to have care in the home, and home health care agencies provide that.

In Montana, home health care providers go the extra mile--literally-- to provide care to patients across vast distances. In some cases, in rural areas they have to drive 100 miles just to see one patient. They are dedicated people. They go great distances and travel a long way to see very few patients.

Home health providers make a real difference in improving seniors' health, and we should support their efforts. We all very much support their efforts.

While I have great respect for the services of home health providers, we also have a responsibility to protect the Medicare Program. Unfortunately, there is almost always waste somewhere. It is a matter of judgment as to how much is waste and how much is not.

We must make sure Medicare is paying appropriately; that is, that Medicare is not overpaying for Medicare services. We must take action to root out fraud and abuse in the Medicare Program generally and where it may occur in the home health industry as well.

I think the policies in the Senate bill achieve both goals. First, the Senate bill would ``rebase'' home health payments to ensure payments reflect actual costs of providing care. These changes are based on recommendations by MedPAC, which is the independent advisory commission that advises Congress on Medicare reimbursement. It is a nonpartisan group. MedPAC advises that we rebase. What do we mean by ``rebase''?

When the current home health payments were set, seniors received an average of 31 visits per episode. Today, they receive 22 visits; that is, they get paid about the same for doing less. We are trying to make sure the payment reflects the actual services provided. The Senate bill directs CMS to rebase payments to reflect this change. It is common sense. MedPAC recommended it and thinks it has to keep up with the times. Times have changed over the years, and the payment system should reflect that change.

There is something else I think is pretty important, and most of my colleagues would agree, the Senate bill roots out fraud that, unfortunately, exists in home health care as well as in other areas of Medicare spending. It tries to root out the fraud in Medicare payments for outlier cases.

Medicare provides an extra payment today for providers--home health folks--who treat sicker people, otherwise known as outlier patients-- really sick, outliers. Unfortunately, the GAO found that some providers were gaming the system and getting much more outlier payments than they deserve.

For example, the GAO found that in one Florida county alone, home health providers were receiving 60 percent of all total outlier payments. That is nationwide. One county was getting 60 percent, even though they had less than 1 percent of the total Medicare population. I don't want to just single out Florida. Other counties in the southern part of the country clearly have a grossly disproportionate amount of high outlier payments.

The Senate addresses this problem by placing a cap on the amount any individual provider can receive in outlier payments.

Another change is the bill makes ``market basket'' changes in 2011 and 2012. That was recommended by MedPAC. Why is that important? MedPAC is actually much tougher. They wanted to start in 2010. We said we will hold off a bit. We wanted to be fair to the home health providers. In addition, the bill establishes a productivity adjustment for home health providers beginning not right away, not next year or the following year but in 2015.

These changes ask home health providers--like all other providers--to offer more efficient and higher quality care over time. We are being fair about it. Very importantly, in making these changes we worked closely with the home health industry to ensure these changes were reasonable and fair.

What do we do with respect to the agencies to make sure we are fair? On the rebasing policy, MedPAC recommended that we fully implement these changes in 2011. To ensure that providers can adapt to the new payment rates, we in the Senate decided we would phase in these changes over 4 years. The home health providers support this phase in. They think it is a good idea.

On the outlier policy and the fraud changes, these policies were actually suggested to us by--guess who--the home health industry. They came to us and suggested we make some changes in outliers because too many agencies are gaming the system. They asked us to make some outlier changes and stop that gaming, to make changes to stop the fraud. They came to us and gave us some ideas. Obviously, the home health industry fully supports the changes they recommended to us. They are in this bill.

On the market basket and productivity changes, the Senate bill holds off on applying these reductions while the rebasing policy is taking effect.

This bill gives home health agencies extra time--much more time than is recommended by the very aggressive proposed changes by MedPAC, the House bill, and the administration. We say those are too aggressive. We in the Senate decided to give agencies extra time to adapt to the payment changes in the bill rather than having all these implemented at the same time as MedPAC and the House and the administration all recommended.

Finally, with respect to rural home health providers, we are all very sensitive to the special needs of rural America. What did we do about that? From 2010 to 2015, rural providers will receive a 3-percent extra payment each year. This payment will ensure that rural providers are protected as we reform the home health system.

In total, the home health changes in the Senate bill, I believe, strike a fair balance between ensuring seniors have access to home care, while also rooting out inappropriate payments from the system.

I hear some of my good friends say: Gee, these changes are going to hurt seniors. They are not going to hurt them. In fact, most of the changes are suggested by the home health care industry. I think all of us want to root out fraud and waste. Also, it is claimed that Medicare beneficiaries will be harmed by this bill. This is a scare tactic.

Let me say what the American Association of Retired Persons says about these claims that these changes in Medicare reimbursement are going to harm seniors.

AARP says:

Opponents of the health reform won't rest. [They are] using

myths and misinformation to distort the truth and wrongly

suggesting that Medicare will be harmed. After a lifetime of

hard work, don't seniors deserve better?

That is AARP. I don't suggest tonight that any of our colleagues are using myths and misinformation to distort the truth. The point is, AARP claims that is not true. They support the bill strongly.

I will remind my colleagues of some of the positive changes in the legislation. This legislation improves the solvency of the Medicare Program by 5 years. It puts $30 billion back into the pockets of seniors in the form of lower Medicare premiums. It makes prescription drugs more affordable, which is an added benefit in this bill that would not be available if the legislation is not passed. The bill guarantees that seniors can continue to see a doctor of their choosing. The bill provides free wellness and prevention benefits. Those are new benefits. They don't currently exist. It will also include fair and appropriate changes for home health that protect access to care.

I don't question the motives of my colleagues. They believe they are standing up for seniors in opposing the home health changes. But in truth they will harm them because they are hurting the Medicare Program. I don't think we want to hurt the Medicare Program. We are trying to help the Medicare Program by making these changes.

There is one other point I want to make. This is kind of interesting. I thought when I saw it--if I still have it--it is kind of interesting. The growth rate in home health care spending will continue to be very high after this legislation passes. Currently, the growth rate of the home health care industry is almost 11 percent per year. After the legislation, it will be almost an 8-percent annual growth in the home health care industry. That is much faster than the national health expenditures.

I think most things in life are a judgment call. I think one fairly decides that the changes in this bill are good for seniors and home health care providers because they are sensitive to the needs of the industry, sensitive to patients, frankly, but also responsible to the American taxpayers by making sure we are rooting out waste.

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

Mr. President, I ask unanimous consent that Sarah Allen, Ryan Nalty, and Grant Jamieson, staff of the Finance Committee, be granted the privilege of the floor for the duration of debate on the health care bill.

Mr. President, I ask unanimous consent that Sara Velde of Senator Harkin's staff be granted the privilege of the floor during the duration of today's session.

I ask unanimous consent that the Committee on Homeland Security and Governmental Affairs be discharged from further consideration of S. 2129 and the bill be referred to the Committee on Environment and Public Works.

Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of Calendar No. 212, S. Res. 341.

I ask unanimous consent that the resolution be agreed to, the preamble be agreed to, the motions to reconsider be laid upon the table, with no intervening action or debate, and any statements relating to the resolution be printed in the Record.

Mr. President, I ask unanimous consent that the Senate now proceed to the consideration of S. Res. 370, submitted earlier today.

I ask unanimous consent that the resolution be agreed to, the preamble be agreed to, and the motions to reconsider be laid upon the table.

I ask unanimous consent that when the Senate completes its business today, it adjourn until 10 a.m. on Saturday, December 5; that following the prayer and pledge, the Journal of proceedings be approved to date, the morning hour be deemed expired, the time for the two leaders be reserved for their use later in the day, and the Senate resume consideration of H.R. 3590, the health care reform legislation, with the first 3 hours following any leader remarks equally divided between the two leaders or their designees and controlled in 45-minute alternating blocks of time, with the majority controlling the first block, and with no other motions or amendments in order during the controlled time.

Mr. President, Senators should expect rollcall votes tomorrow afternoon. There will be no rollcall votes prior to 1 p.m.

If there is no further business to come before the Senate, I ask unanimous consent that it adjourn under the provisions of S. Res. 370, as a further mark of respect to the memory of the late Paula Hawkins, a former Senator from the State of Florida.

Thereupon, the Senate, at 6:50 p.m., adjourned until Saturday, December 5, 2009, at 10 a.m.

Madam President, I yield myself 2\1/2\ minutes from the time under the control of the managers.

For the benefit of all Senators I want to take a moment to lay out today's program.

The time between now and 11:45 is for debate on the amendment by the Senator from Maryland, Ms. Mikulski, the chairwoman of the Subcommittee on Retirement and Aging of the Health, Education, Labor and Pensions Committee.

And at the same time, we will debate the side-by-side amendment by the Senator from Alaska, Ms. Murkowski.

At 11:45, the Senate will conduct two back-to-back rollcall votes on the two amendments, first on the amendment by the Senator from Maryland, and second on the amendment by the Senator from Alaska.

Thereafter, we will conduct approximately 2 hours of debate on the McCain motion to commit on Medicare and the side-by-side amendment by the Senator from Colorado, Mr. Bennet.

At 2:45, the Senate will conduct two back-to-back votes on the amendment by the Senator from Colorado, followed by a vote on the motion to commit by the Senator from Arizona.

Thereafter, we expect to turn to another Democratic first-degree amendment and another Republican first- degree amendment.

This is the fourth day on this bill, and we are only late this morning coming to our first vote. Even for the U.S. Senate, this is a slow pace.

I note that some have made plans for delaying this bill in even more extreme fashion. As the majority leader noted, on Tuesday, one Senator circulated a list of delaying tactics available under the Senate rules.

I presume all Senators know the Senate's rules already. So to send the letter leaves the impression that that Senator would like to urge Senators to use some of the delaying tactics stated in the memo.

But I urge a more cooperative course. Out of courtesy to other Senators who desire to offer amendments. I urge my colleagues to allow us to reach unanimous consent agreements to order the voting of future amendments in a more timely fashion. That is simply the only way that we can ensure that more colleagues will have the time and opportunity to offer and debate their amendments.

I thank all Senators.

I ask unanimous consent that the order of December 2 be modified to delete all after the word ``table.''

I ask unanimous consent that the debate time from 2 to 2:45 this afternoon be divided as follows in the order listed: the first 17\1/2\ minutes under the control of Senator McCain or his designee; the next 17 minutes under the control of Senator Baucus or his designee; and the final 10 minutes, 5 minutes each for Senator McCain and Senator Bennet of Colorado.

Madam President, I think it is perfectly understood.

Madam President, will the Senator yield for a quick inquiry to my friend from Wyoming?

Madam President, I might inquire of my colleague from Wyoming if that item the Senator was quoting from about costs in the Wall Street Journal was a news article or an editorial.

Mr. President, I am going to speak very briefly on the pending subject and then let the sponsor of the amendment, that is the Mikulski amendment, finish up here. I think it is very telling--I know this point has been made before but I think it bears repeating--the American Heart Association, American Stroke Association has written and released to the Senate this letter. I will read the most important part here. Basically they say they strongly support requiring health plans and Medicare providing first dollar coverage for clinical preventive services that are evidence based and necessary for the prevention or early detection of an illness or disability. We all agree with that.

They go on then to comment on the Murkowski amendment, saying they appreciate the Murkowski amendment recognized the value of the guidance and recommendations but they go on to say that even these guidelines must be held to a standard of being evidence based.

I might say, I run across this over and over again in the medical profession--medical experts. We need to keep moving more and more toward evidence-based medicine.

This statement from the American Heart Association, American Stroke Association, goes on to say:

In addition, we are concerned that Senator Murkowski's

preventive health services amendment would take a step

backwards by substituting the judgment of the independent

U.S. Preventive Services Task Force with the judgment of

private health insurance companies.

Frankly, it is a point I very much agree with. I don't think we want the judgment of private health insurance companies making these decisions. I think it is appropriate the sponsor of the amendment finish. She is doing a very good job.

Mr. President, I wonder if the Senator from Wyoming would be available to answer a question.

I am thankful to my good friend and neighbor to my State.

Is it true the CBO letters say the Senate bill will extend the life-- extend the solvency of the Medicare trust fund? Is that true?

I don't have the letter in front of me, but in all deference and respect to my good friend from Wyoming, the CBO says the exact opposite. It is the conclusion of the Congressional Budget Office that this legislation will help seniors by extending the solvency of the Medicare trust fund by, I guess, 4 to 5 years. That is black and white. If I had the letter in front of me, I could read it to him, but that is a

fact. This legislation will extend the solvency of the Medicare trust fund by another 5 years.

So instead of being insolvent in the year 2017, under this legislation, that is extended to the year 2022. That is a fact. At least the fact is that is what CBO concludes in their letter. That is a fact.

Second, as a caring physician, does the Senator think that we as a country should try to find a way to provide health insurance for so many Americans--some of them lower income--who don't have health insurance in our country? Because, after all, we are the only industrialized country in the world that doesn't find a way to make sure its citizens have health insurance.

As a physician who sees patients, many of whom can't pay their bills and defer medical treatment because they do not have health insurance, I am wondering if the Senator believes this country should try to find a way where its citizens have health insurance.

I will ask this question, and then I will finish because I know my colleagues want to speak.

One of the basic underpinnings of this legislation is that we should change the way we reimburse providers, moving away from quantity and volume and more toward quality. I am curious--and this is not an antagonistic question. I am just trying to get a physician's point of view because so many doctors I talk to think that although it creates a little uncertainty, probably that is the right thing to do--to move our reimbursing based on quality, coordinated care, and focusing on the patient rather than our current system, which reimburses more on quantity and the number of services provided, et cetera.

Is that something the Senator thinks we should pursue in this country?

I agree.

Mr. President, I have to address that one. My colleagues want to speak, but I think it is worth repeating over and over again: This legislation is designed to retain the uniquely American solution to health care--roughly half public, half private. It is designed to make sure patients can still, as they should, choose their own doctor, any doctor they want--primary care doc, specialist, no gatekeepers and all that stuff. The doctors are totally free and should be free to make their own decisions, after consultation with their patients, as to what procedure makes sense or doesn't make sense.

In addition to that, frankly, more competition with the exchanges. This legislation, frankly, is rooted almost entirely on maintaining the current free market system in health care. There is some insurance market reform, which I think everybody agrees with, which is denying preexisting conditions as a basis for denying coverage, and there is a modest expansion of Medicaid for lower income people who just can't get health care, but otherwise this is legislation which is rooted in the current American system.

We have a good system. It works. This is just designed to make it work a little better by making sure it reimburses, as the Senator from Wyoming wants, based more on quality. He didn't mention this, but I know he agrees, also insurance market reform so those patients who come to him don't have to wait until the end of the year in the future as they have in the past.

But I want to get it very clear, this is no ``government takeover.'' That is a scare tactic. It is not accurate. It is basically maintaining our current system.

I would now like to yield 10 minutes to my good friend from Vermont.

Mr. President, I ask how much time is remaining on each side?

Mr. President, I yield 9 minutes--how many seconds?

I yield 9 minutes 11 seconds to the Senator from Iowa.

Mr. President, I do not think I have any time, but I ask unanimous consent that as to the time I do have after 2 o'clock, I can take 2 minutes of that so I can ask a question of my good friend from Iowa.

Mr. President, I might ask my friend from Iowa, Senator Grassley, a question, if he is available for a question. I am taking time.

I understand. I do not want to cut into that time at all.

I am taking it off my time, not your time.

Is it true the Congressional Budget Office said this bill, over 10 years, is not only deficit neutral but actually decreases the budget deficit by about $130 billion? Is that true? Is that what the Congressional Budget Office said?

Well, I do not know--to be totally fair and respectful to one of my very best friends in the Senate--to cover that point, isn't it also true the Congressional Budget Office said in the second 10 years this bill will reduce the budget by one-quarter percent of GDP? Isn't that also true, according to the Congressional Budget Office?

We trust each other. We both trust each other. That is what the letter says.

Thank you.

I will yield myself about 10 minutes. The Senator from Tennessee says this is going to hurt seniors. Let's ask the senior organizations what they think about that.

Let's also look at this organization called 60 Plus. What does the AARP say in the letter to Senator Reid, dated December 2? It talks about this legislation:

The legislation before the Senate properly focuses on

provider reimbursement reforms. . . .

I am sorry all my colleagues have fled the Senate. I would like for them to stay and listen to this. I would like to hear their response. But they have just fled the Senate after making sound bites.

I will take my time. The AARP letter, dated December 2, states:

The legislation before the Senate properly focuses on

provider reimbursement reforms. . . .

Most importantly, the legislation does not reduce any

guaranteed Medicare benefits.

That is AARP. All this is scare talk about ``grandma.'' With all due respect to my friend from Tennessee, he says that. He has been using that phrase a lot. But AARP says that grandma is fine. AARP says:

Most importantly, the legislation does not reduce any

guaranteed Medicare benefits.

It doesn't reduce any benefits, according to AARP. Going on:

AARP believes that savings can be found in Medicare. . . .

The savings in Medicare will extend the solvency of Medicare. I am sure my friend from Tennessee knows the actuary said this legislation extends the solvency of Medicare, helps Medicare. The benefits go on longer than the status quo. Also, it does so, according to AARP, by eliminating waste and inefficiency and aggressively rooting out fraud and abuse. The last sentence is:

We therefore urge you to oppose the McCain amendment to

recommit. . . .

The AARP says this hurts seniors, the McCain motion to commit. I think the job of the AARP is to figure out what is best for seniors. That is their conclusion.

It is not just AARP's view. There is another letter. This is from the National Committee to Preserve Social Security and Medicare. They say basically this legislation doesn't cut Medicare benefits. Again, this is the National Committee to Preserve Social Security and Medicare. They say, rather, this legislation includes provisions to ensure that seniors receive high-quality care and the best value for their Medicare dollars. That is a very reputable senior organization. AARP is a very reputable senior organization. The National Committee to Preserve Social Security and Medicare is a very reputable organization. That is what they say.

Who is this 60 Plus association I have heard referred to? Let me just tell my colleagues what 60 Plus really is. I will read this. This is from Wikipedia, and it may not be accurate. It says this about 60 Plus:

The 60 Plus Association is an American conservative

advocacy group based in Arlington, Virginia, that bills

itself as the conservatives' alternative to the AARP.

That makes good sense because over the years it has sought to privatize Social Security. 60 Plus, over the years, has sought to privatize Social Security. They want to end the Federal estate tax. They also want to strengthen gun rights, but that is not relevant.

According to the AARP--

And this is a bit biased--

the 60 Plus Association employed the talents of conservative

direct mail mogul Richard A. Viguerie to solicit new members.

We all know who Viguerie is. 60 Plus is a very conservative organization. I don't think they are real interested in senior citizens. They have different fish to fry. Also, AARP criticized 60 Plus as being partisan because its issues and causes mirror those of only one of two major parties, the Republican Party.

A final criticism leveled by the AARP [about 60 Plus] is

that because it lists no dues-paying members and [get this]

receives the majority of its contributions from the

pharmaceutical industry, the group is simply a front

organization for the pharmaceutical industry.

I ask unanimous consent to have these letters in opposition to the McCain amendment, in support of the Bennet amendment, and the Wikipedia information printed in the Record.

Mr. President, I think it is pretty clear that the main organizations that care about seniors support this bill. Another organization--60 Plus--I don't know what they think. I guess they oppose it because they want to privatize Social Security, and they get most of the money from the pharmaceutical industry. I don't think they care about senior citizens, frankly, and certainly not as much as these other organizations.

I think it is also important to point out that this legislation is deficit neutral over not just the first 10 years but over the next 10 years. It is more than deficit neutral. This legislation generates a $130 billion surplus the first 10 years and, as we all know, reduces the budget by a quarter of GDP over the next 10 years. So this is not irresponsible; it is very fiscally responsible. It is strongly supported by the senior organizations that care for seniors. I might say, too, it is not raiding Medicare at all. It is strengthening the Medicare trust fund and it extends the solvency of the trust fund.

Therefore, I think, clearly, as AARP says, we should oppose the McCain amendment, which hurts Social Security beneficiaries, does not help them.

I yield such time as the Senator from Illinois needs.

Mr. President, I think it is appropriate to remind people of some of the provisions that are in this bill.

To repeat, because some people have listened to some of this debate and some have not and some might be tuning in right now, the fact is, without reform, without this legislation, Medicare is expected to go broke in the next 8 years. That is according to the Medicare trustees report. With this legislation, that is extended for at least 5 more years. That protects seniors. This legislation protects seniors. Without reform, that is, without this bill, costs will rise and seniors will be forced to bear more and more of the burden out of their own pockets. This legislation adds benefits for seniors. It does not take it away, as the other side implies.

Without reform, seniors will struggle to afford prescriptions in the doughnut hole. I remind my colleagues that this legislation will cut the cost of brand-name prescription drugs in half for seniors during that gap, the so-called doughnut hole.

It will also help provide more benefits in terms of annual wellness visits. When seniors go to the doctor for a colonoscopy, mammography, or other preventive screenings, they will not have copays, as is currently the case today. That is an added benefit this legislation provides for seniors.

Also, this legislation helps seniors who are eligible for both Medicare and Medicaid with access to home, community-based alternatives. A lot of our seniors would like that additional benefit. That is all in this legislation.

This legislation provides more benefits for seniors, not fewer. This legislation protects seniors; it does not harm them. This legislation extends the solvency of the trust fund rather than not.

I might also say--and I think the Senator from Illinois made a very good point--currently, seniors who are paying a Part B premium are really paying a $90 tax per year for those persons who are in Medicare Advantage. We know Medicare Advantage is overpaid. The Senator from Oklahoma, Mr. Coburn, agreed with me when I asked him just yesterday if Medicare Advantage was overpaid. He said, yes, it is overpaid by a very large margin. This legislation can adjust that overpayment.

I might also say, too, that the groups I mentioned support this legislation. But the main point I want to make is this: There are so many fundamental provisions in this legislation that really have not come out much in debate, a little esoteric but under the heading of ``delivery system reform.'' We must begin to change the way we reimburse doctors and hospitals so we are focusing much more on quality of care rather than quantity of care. Some of that is already happening in America without legislation. Basically, it is the nature of integrated systems. We all talked about them. I know Senators on the other side of the aisle also agree with this new trend where hospitals, doctors, nursing homes, and other groups get together and they coordinate their care. Their care is much more patient focused. We have to move much more in that direction.

This will go a long way once it starts kicking in--it is going to take maybe 3 or 4 years to finally have an effect--toward eliminating the waste in our current system. Estimates are we have between $200 billion to $300 billion to $800 billion annually in waste in the American health care system. That is the reason health care costs are so high for family, businesses, governments, whatnot. We have to begin to get that under control, and this legislation does that.

If we do not pass this legislation, we will be postponing the day when we have to begin to get some of these excessive costs under control, and then the problem will be much more difficult. An ounce of prevention is worth a pound of cure in medicine. It is also true in legislation. Clearly, now is the

time to exercise a little ounce of prevention by starting to curb excessive costs, and this bill does that.

Reserving the right to object, under current law, if less is spent for Medicare providers, the benefits inure to the Medicare trust fund beneficiaries.

Although I have the greatest respect for the Senator from Iowa, this is a stunt, and I object.

How much time remains?

The Senator from Arizona has yielded back his time. We might as well yield back our time, and we can vote.

Mr. President, I ask my colleague if he wishes to go first? Whatever he wants to do. It is his motion.

Mr. President, the McCain motion is next. Unless we act today and pass health care reform, the Medicare trust fund runs out of money in 2017. There are two ways to keep Medicare solvent: find efficiencies so Medicare spends less or increase revenues going into the trust fund--two ideas. Our bill would make Medicare Advantage more efficient. We would introduce competitive bidding----

I thank the Senator from West Virginia.

We extend the trust fund for 5 more years. That is in this bill. Yes, Medicare Advantage plans would not be overpaid as much, but those plans could pay for greater efficiency by cutting their profits or cutting their executives' pay. They could do that. Nothing says they have to go after beneficiaries.

Our bill does nothing to reduce the guaranteed Medicare benefits. To the contrary, our bill would improve Medicare benefits. It would help seniors on the prescription drug doughnut hole and add new preventive benefits such as annual wellness visits. The bill would help ensure doctors would be available to treat Medicare patients. We would prevent the 21-percent cut in doctor payments under current law. For all those reasons, the American Association of Retired Persons supports reform and opposes the McCain motion.

I urge my colleagues to support reform and oppose the motion to commit.

Mr. President, I move to reconsider the vote.

Madam President, I think it would be instructive to stop all this rhetorical talking past each other on Medicare Advantage and explain a little bit about how we got to where we are in this legislation.

I don't know the exact year, but I think it was back in the 1980s sometime, up to a certain point Medicare was basically paid fees for services. That is the basic Medicare model. The service was provided and there are certain set rates for that service. Then, in the 1980s, private companies thought maybe they could be more efficient, private insurance companies. So they came to Congress and said: We can do a better job in compensating Medicare based on fee for service, so let's set up something called Medicare Advantage, private entities.

So Congress said: OK, competition is a good thing. So we did that. Congress did that. We basically set the rates to be paid to Medicare Advantage plans at 95 percent of fee for service. After all, the plan said they could do it more cheaply and they could compete. So we said: OK, that sounds like a good idea. We will pay you 95 percent of what otherwise would be paid under fee for service. That continued for a while.

In 1997, the plan said: Gee, we need a little more money. So Congress said: All right. And we gave a little more money to Medicare Advantage and basically said, OK, that will pay the 95 percent. But if you are not doing so well and making money at 95, we will set kind of a higher floor, according to certain areas of the country, and you could choose whatever enables you to have the greatest compensation.

The big change occurred in 2003, in the Medicare Modernization Act, otherwise known as the drug bill. It was the legislation that created drug benefits for seniors. As we all know, frankly, when Medicare was created, it didn't have an outpatient drug benefit because drugs weren't comparatively as important then as they are today. Today there are miracle drugs that help in a lot of ways. We created the drug benefit in 2003.

The Congress did something else then. Many Members of Congress were concerned that Medicare Advantage might not offer the plans in rural parts of America, that there wouldn't be enough incentive for Medicare Advantage to go to rural America to offer the drug benefits--not only the drug benefits but other benefits they provided. Congress, frankly, gave a lot of money to Medicare Advantage plans so there could be at least two plans operating in all parts of the country. Give them enough money and they will go; that was the theory. Guess what happened. We gave them a lot of money and they went.

We have reached the point now where Medicare Advantage is, by everybody's estimate, quite dramatically overpaid, as the Senator from Oklahoma, Mr. Coburn, said when I asked him yesterday whether Medicare Advantage plans are overpaid. He said, ``Yes, they are definitely overpaid.''

MedPAC, which advises us on Medicare reimbursement, said to us that we are way overpaying Medicare Advantage plans. I hear figures of from 14 to 18 percent overpayment. It depends on what part of the country you are in. Let's be conservative and say it is 14 percent in fee for service, that they are overpaid. MedPAC is an independent advisory group that helps us figure out what in the world we pay hospitals, nursing homes, home health agencies, etc. We are not the experts. We need help. MedPAC said to the Congress that we are overpaying them big time.

We decided let's figure out a way to reform the system. How about a little competition? Right now, Medicare Advantage plans are paid what is called a benchmark, depending upon the fee for service in their certain area. We all know fee for service is much less in rural America, and I am sure in the home State of the occupant of the chair. Fee for service is much higher in other more urban States and so forth.

As it turned out, under the benchmarks for fee for service, they were way overpaying in States where fee for service is so high, and not quite as much overpaid where fee for service is so low. That is a nutty system in the current law today.

What we are doing in this legislation is, basically, we are saying: Look, let's introduce a little competition. We are saying: Let's get rid of the benchmark-type fee for service. It is out of whack in different parts of the country. What are we going to do? We say: OK, we will divide the country into geographic areas. In your area, wherever you might be, Uncle Sam--or Medicare--will pay the average competitive bid

for that area. The average cost you bid for that area is what we are going to pay, which eliminates this big disparity between States and makes it much more fair so that reimbursement is based much more on what it actually costs in a certain area, but it is competitively bid. That is what we are trying to do.

Is that a good thing to do? I think most of us think so. Is it perfect? I don't know for sure, but we are trying our best to make this a better system, a better program than we currently have. As a consequence, we are going to save some money, and there will be competition. Most of us think competition is often a pretty good thing. That is what this is, I remind my colleagues. As a consequence, we are not going to be overpaying Medicare Advantage plans anymore. The amount we reduced the payment to is in line with what MedPAC says we should pay, the Medicare Payment Advisory Commission.

We are trying to be responsible and reasonable with taxpayer money, seniors who pay into Medicare. The point is often made that, gee, this will hurt Medicare Advantage, hospitals, and so forth. I think it is worth reminding all of us that a meeting occurred at the White House, I think, 4 to 6 months ago, when all of the so-called providers--the hospitals, insurance companies, including Medicare Advantage plans--all got together with the President and said: Mr. President, we agree this country needs health care reform. They all agreed.

Let's move back in history a little bit. When President Clinton attempted health care reform, all those groups were opposed to health care reform. This time, they are pretty much in favor of it because they know if we don't fix it, it is going to collapse.

Back to that meeting. What did they say? They said: Mr. President, we have all gotten together and we think we can contribute. We can cut collectively $2 trillion in payments that go to us over the next 10 years.

That is what they said. That is pretty interesting. Thank you very much. So we are working together to get health care reform.

Why do you think they would agree to $2 trillion? They got their calculators out and got their financial officers together and said: Gee, if everybody has health care--remember, 46 million Americans don't have health insurance--if everybody had health insurance, hospitals, Medicare Advantage plans said: Hey, we can make some money because everybody has health insurance.

So that was the deal. They will have a little lower margins, but they will make it up on volume. That is why they said to the President: We can cut $2 trillion that otherwise would be reimbursements to us.

In this legislation, did we reduce the rate of increase over 10 years by $2 trillion? No. Did we decrease the rate of increase in expenditures by half of that or $1 trillion? No. Do we reduce the rate of increase of health care expenditures down to, say, $450 billion, close to $500 billion? Yes, that is what we did. About one-quarter of the industry said they could voluntarily contribute. Are they squawking today? No. Why? Because they got a pretty good deal. They know they can continue to provide services and the hospitals are going to do well and home health care agencies will do well. I will add that the profit margin for home health agencies is about 17 percent. That is pretty good. So we are cutting them a little bit. The profit margin for nursing homes--Medicare payments to nursing homes--is about 15 percent. We are cutting that a little bit. But they are still making money and still will do well. In fact, their average rate of growth over the next 10 years is going to be in excess of 5 percent a year. Wall Street analysts say these outfits are doing pretty well. You don't see their stocks going down.

We are trying to do what is right and to reform Medicare Advantage, as I just outlined it. It is a pretty fair attempt at reform. Also, we will reduce payments to hospitals and other providers in an amount that they can live with--not be happy with but an amount they are OK with, and where they know they can still make money. That extends the solvency of the Medicare trust fund another 5 years because those providers are not being paid as much as they would otherwise be paid.

I hear Senators crying crocodile tears about how seniors are going to be cut, and so forth. Frankly, with the changes we made, I think it is very fair, and it will extend the solvency of the trust fund. There is not one dime of guaranteed Medicare benefits that will be cut--not one thin dime--in this legislation. It is true that because Medicare Advantage--the rate of growth of increase in Medicare Advantage plans is trimmed back a little, perhaps there will not be as many extra benefits--not the guaranteed benefits but extras, fringe benefits, like gym memberships and things like that. Don't forget, that is not because that is a decision made by Medicare or by Congress; that is a decision made by the executive offices of these private companies. I am not saying they should do this. They could trim salaries, overhead, and they could have a little less return to stockholders, and they could cut down administrative costs. There are various things they could do, which doesn't have to be passed on to reductions in fringes. Let's keep things in perspective as to what is actually going on.

Most people did.

That is correct. To be totally fair, the other side likes to trot out this Medicare pamphlet that includes Medicare Advantage. I think that is misleading and not accurate. As the Senator says, these are private plans.

Absolutely. That was the rationale.

That is correct. It depends on the part of the country.

That is correct.

Exactly.

With great considerable administrative costs and profits that otherwise could go to seniors.

Congress did. Congress set the benchmarks.

That is correct.

That is correct. Under this legislation, we say--frankly, under the earlier Medicare Advantage plans, HMOs had some coordinated care, but the other half, the private fee for service, preferred provider organizations did not have coordinated care.

We are saying in the legislation that if you are in the Medicare Advantage plan, which includes a whole list, and you provide coordinated care, we are going to give you a bonus.

That is a very interesting question. When I was told about the handbook, that is what I thought I was going to do, is call up Medicare and say that is misleading and it is inaccurate because it is misleading and it is inaccurate.

These are private companies.

It has officers, a board of directors.

This is a semantic question. When you see the operational effects, as my good friend from Connecticut said----

This legislation, if I may say, expressly states there will be no reduction in what is called guaranteed benefits under Medicare. No reduction, whether it is under Medicare Advantage, whether it is under fee for service--whatever it is, no reduction whatsoever.

To be fair to my good friend, I used the words ``guaranteed benefits.'' Guaranteed benefits are the usual benefits seniors think of when they are under Medicare. They go to a doctor, hospital, so on.

We have given, unfortunately, so many additional dollars to the so- called Medicare Advantage plans--way above what they should have received. MedPAC agrees. Senator Coburn totally agrees they have been paid way too much. They have taken advantage of that advantage by giving additional benefits, in addition to the guaranteed benefits. Those additionals are things such as gym memberships--a lot of extra stuff that, frankly, is not part of Medicare, is not directly related to health.

I might say, too--I have said this a couple, three times and I will say it again--a reduction in the increase of payments to Medicare Advantage, the effect of those reductions is a decision made by the officers of that company. They could take those reductions and apply them anywhere. They could reduce their salaries. They could reduce their admin costs. They could take other actions that would reduce the rate of growth, the rate of return of their stockholders. They do not have to take it out of the beneficiaries. That is their choice. They do not have to.

I wish to say something else to put this in perspective. That is according to analysis of Medicare Advantage plans from Oppenheimer Capital Fund, dated November 12 of this year, between 2006 and 2009. Their estimate is, Medicare Advantage accounted for nearly 75 percent of the increase in gross profits among the larger Medicare plans in the industry.

Let me say this:

. . . Medicare Advantage . . . has been a huge driver--

Quoting from the Oppenheimer Capital Fund--

a huge driver of earnings growth for the industry in recent

years. Between 2006 and 2009, we estimate that Medicare

Advantage accounted for nearly 75 percent of the increase in

gross profits among the larger plans in the industry,

highlighted by an estimated gross profit increase of $1.9

billion in 2009, relative to commercial risk earnings gains--

That is basic health insurance, not Medicare Advantage plans but basic health insurance--

of nearly $600 million. Medicare Advantage probably won't be

as much of a contributor in 2009--

But it is going to be a very large contributor in 2009 because of advantages they get.

I might add, too, to remind us all, this legislation provides additional benefits for all seniors, including Medicare Advantage recipients--additional benefits. What are they? No copayment for certain preventive care--mammograms, for example, colonoscopies, screening benefits that are not in existence today. There are a whole host of other things that are additional.

This legislation provides additional benefits to Medicare Advantage members that are not there today.

When I say ``guaranteed benefits,'' I am talking about the usual benefits seniors think of under Medicare. It is hospital care, it is nurses, it is all medically necessary physician care, diagnostic testing, supplies. It is home health care, preventive care, skilled nursing, hospice--all the things that are basically related to health care.

The only thing that might be trimmed back a little is, I call them the fringe stuff, the excesses, such as gym memberships. I wish I had the whole list because some of them are not related.

As I said earlier, they may not be cut. They don't have to be. It is up to the private companies whether to cut. I have nothing against companies making profits. They should make profits. It is our responsibility as Senators to make sure the reimbursement rates Medicare pays providers are fair and reasonable and not excessive. We have been told they are excessive. So we are trying to find a way to make it fairer.