Floor Statements

Mr. President, I ask unanimous consent that the Committee on Banking, Housing, and Urban Affairs be authorized to meet during the session of the Senate on December 3, 2009, at 10 a.m.

Mr. President, I ask unanimous consent that the Committee on Commerce, Science, and Transportation be authorized to meet during the session of the Senate on December 3, 2009.

Mr. President, I ask unanimous consent that the Committee on Energy and Natural Resources be authorized to meet during the session of the Senate to conduct a hearing on December 3, 2009, at 10 a.m., in Room SD-366 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 3, 2009, at 9 a.m., to hold a hearing entitled ``Afghanistan: Assessing the Road Ahead.''

Mr. President, I ask unanimous consent that the Committee on Homeland Security and Governmental Affairs be authorized to meet during the session of the Senate on December 3, 2009, at 10 a.m.

Mr. President, I ask unanimous consent that the Committee on Indian Affairs be authorized to meet during the session of the Senate in Room 628 on December 3, 2009, at 2:15 p.m. of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Committee on the Judiciary be authorized to meet during the session of the Senate on December 3, 2009, at 10 a.m., in Room SD-226 of the Dirksen Senate Office Building, to conduct an executive business meeting.

Mr. President, I ask unanimous consent that the Select Committee on Intelligence be authorized to meet during the session of the Senate on December 3, 2009, at 2:30 p.m.

Mr. President, I ask unanimous consent that the Subcommittee on National Parks be authorized to meet during the session of the Senate to conduct a hearing on December 3, 2009, at 2:30 p.m., in Room SD-366 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Subcommittee on Water and Wildlife of the Committee on Environment and Public Works be authorized to meet during the session of the Senate on December 3, 2009, at 2 p.m. in Room 406 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that Stacey Sachs, a detailee in the Senate HELP Committee Majority Health Office, be granted the privileges of the floor for the duration of H.R. 3590, the Patient Protection and Affordable Care Act.

Mr. President, I noted that the other side, in the last couple, 3 days, has tried to make the case that seniors' Medicare benefits are in jeopardy because ``this legislation cuts Medicare.'' I have heard that statement over and over and over and over again. In fact, the last speaker on the other side made that same point.

I am confounded, I am very surprised, when I hear those statements. Why am I very surprised? Because it is totally, patently false. It is false. It is untrue. There are no benefits cut here, none. One could say that with the private plans, the Medicare Advantage plans, which are vastly overpaid--the nonpartisan MedPAC organization states they are vastly overpaid by about 14 percent--one could say those private plans--it is not Medicare; those private plans, Medicare Advantage; those are not Medicare plans, those are private plans, private insurance plans--they may be overprescribing some nonguaranteed benefits for beneficiaries, things such as eyeglasses or something like that, which might be cut back. That is true. But none of the guaranteed benefits--the basic benefits under Medicare that every senior knows about when he or she goes to the doctor; and it is care under Medicare--is reduced. None. Nothing is cut.

In fact, this legislation adds benefits to seniors. For example, it virtually fills up this thing we call the doughnut hole. That is the portion of prescription drug payments that seniors otherwise would have to pay. But we say $500 of that is going to be paid for, and the rest of it is going to be paid for at least for 1 more year. So that is an additional benefit. Then all the screening provisions that are in this bill, that is an additional benefit. There are many other benefits that are added onto the ordinary benefits seniors have.

So it is not true--it is not true--that the basic guaranteed benefits under Medicare are cut. None of the guaranteed benefits under Medicare are cut--none. So it is totally untrue. It is false when people make the claim that ``Medicare is being cut.''

They are being very clever, the people who are making those claims. What they are saying when they say Medicare will be cut--they want you to think they mean benefits will be cut--but deep in their mind, what they are holding back in their mind--well, when pressed, they will agree, well, it is the Medicare providers, it is the hospitals, it is the medical equipment manufacturers, it is the pharmaceutical industry. That is being cut. That is ``Medicare'' that is being cut and, therefore, that will hurt seniors. That is kind of the way they get around it.

Well, the fact is, the way you preserve the solvency of the trust fund is to make sure there are not so many payments, frankly, by Uncle Sam going to pay for all the doctors and hospitals and so forth so the solvency of the trust fund is extended. Right now this legislation extends the solvency of the Medicare trust fund. If this legislation were not to pass, the Medicare trust fund would probably go insolvent in about the year 2017. But this legislation extends the solvency of the trust fund for at least 5 more years to 2022.

So I wish to make it very clear that this legislation we are considering does not cut Medicare benefits. In fact, the hospitals and docs, I would say, are going to find at least a 5-percent increase in growth over the next 10 years in payments to them under the Medicare Program--growth. I have a chart which I showed yesterday on the floor. It showed, for each of the various years, it is a 5-percent increase in growth for all those industries. They are being cut 1.5 percent, but that is from a 6.5-percent growth, to net down to a 5-percent growth for each of the years.

You ask analysts on Wall Street how hospitals are doing. They are doing great under this legislation. You ask analysts on Wall Street how the pharmaceutical industry is doing. They are doing great under this legislation. You ask any analyst about other industries--home health care, hospice care, you name it--they are all doing OK. Wall Street analysts say they are doing fine.

Why are they doing fine? Why, objectively, are they doing fine? Why do the CEOs of these organizations not grumble too much? Because they know what they may lose in a little bit of a reduction in their payments--they will still get big, hefty payments--they will make up in volume because so many more people will have health insurance. They know that. They are going to make a lot of money. So they are OK.

So it is not true that Medicare is going to go broke under this legislation. First of all, there is no reduction in benefits. That is very clear. Senator Dodd read a letter from AARP making that very clear. Also, the reductions are not reductions in provider payments; they are reductions in the rate of growth of provider payments, and they are going to do fine. Providers do not care that much because they are making it on volume because everybody is going to have health insurance. They have quite a bit--a 5-percent growth rate anyway. So it is not true--it is not true--that Medicare is in jeopardy because of this legislation. It is not true that benefits are going to be cut. In fact, just the opposite is true. This legislation strengthens benefits, increases benefits, extends the length of the Medicare trust fund to a future date further down the road, so it stays solvent for many years than otherwise is the case.

This legislation helps seniors. It helps seniors, contrary to what you are hearing on the other side that it hurts seniors. If you just look at the facts, not the rhetoric--not the rhetoric but just look at the facts, look at the facts and look at who the supporters of this legislation are and objective groups and what they say about this legislation--you cannot help but be compelled

to the conclusion that this legislation is not only good for seniors, it is very good for seniors.

Recognition of the Minority Leader

Mr. President, the Republican leader a few moments ago said this bill raises costs. With all due respect to my good friend from Kentucky, that statement is false.

Just this week, the nonpartisan Congressional Budget Office, the organization that analyzes legislation--and both sides, both bodies depend on it; it is a very professional outfit, I might add--said our bill would reduce premiums, not increase but reduce premiums for 93 percent of Americans. And for all Americans, it would make sure that better quality insurance is available.

Let me state that a little bit differently. The Congressional Budget Office said that for 93 percent of Americans, premiums would be reduced. It is true that for 7 percent that is not the case. Those are Americans whose incomes are too high to qualify for subsidies; that is, the tax credits, buying insurance in exchange. But those 7 percent would get a lot better insurance, a lot higher quality insurance than they get today because of the insurance market reforms that are in this legislation. The provisions prevent insurance companies from denying coverage based on preexisting conditions, health status, the committee market rating provisions, no rescissions, et cetera. So for all Americans, it is true that this legislation will provide better quality insurance comparing apples with apples. There is a reduction for 93 percent of Americans. The other 7 percent would be in the individual market and they would have a lot higher quality insurance. So if the quality is much higher, it would exceed the increase in premiums. They would be getting a better deal than they would otherwise be getting.

CBO looked at this for the year 2016. They didn't look at it for other years, but at least that is the case for 2016: a reduction, not an increase but a reduction. In fact, for many in the nongroup market, those who individually buy insurance, they would find their premiums would be reduced about 40 or 50 percent. About 60 percent of those in the nongroup market are finding their insurance premiums would be reduced. I don't have the exact figure in front of me, but it is in the neighborhood of a 40- or 50-percent reduction in premiums. That is due to tax credits. Again, CBO says those tax credits would cover nearly two-thirds of premiums. So I guess I was a little conservative. It is a little more than 40 or 50 percent. It would cover two-thirds of premiums.

CBO said those getting these tax credits would pay for roughly 56 percent to 59 percent lower premiums than they would without our bill. Those are real savings. That is with respect to the premiums.

What about out-of-pocket costs? This legislation has absolute limits on out-of-pocket costs. Today insurance companies can sell you a policy, you pay certain premiums, but there is no limit on the out-of- pocket costs you might have to pay. Your deductible is so high, for example. This legislation puts an absolute limit so no policy can be sold that allows you to have out-of-pocket costs above a certain amount. I think it is $6,000 for an individual, and it might be double that for a family. But there is a limit. So this bill does not, as stated by the minority leader, raise costs. In fact, it reduces costs.

In addition, there are many people who say, Oh, gosh, this is a $1 trillion bill. Some people even say it is a $2.5 trillion bill. Senators on the other side of the aisle make those statements and they say this to try to scare us.

I will be honest with you. I don't know if they believe it. They like saying it because it is a nice, good scare tactic. I say I am not sure they believe it. I wonder if they believe it, because when you read the legislation, it is deficit neutral. It does not add to the deficit.

We have a budget resolution. Under that budget resolution, health care legislation for the next 10 years has to be deficit neutral. It cannot add one thin dime to the deficit. So I am a little curious when people talk about a $1 trillion bill. In fact, it reduces the deficit by $130 billion over a 10-year period. That is what the Congressional Budget Office says, the professional nonpartisan budget office.

In the second 10 years, the CBO says our bill reduces the deficit by a one-quarter of 1 percent of the gross domestic product. That is roughly $\1/2\ trillion. In the second 10 years, this legislation reduces the deficit by $\1/2\ trillion. That is a reduction in the deficit.

I don't know why these people are saying on the other side that this is a trillion-dollar bill. One said--and I will not mention his name-- the other day that this is a $2.5 trillion bill. That is not true. It is just not true because it is paid for. It would only be fair for them to say it is paid for. I think it is fair to get both sides of the story, not just one side. It does cost $1 trillion over 10 years, but it is more than paid for over 10 years. Those who say $2.5 trillion-- they start at 2014 up to 2020, and say that is why it costs so much. It is paid for during those years, too.

Let me make it very clear this bill doesn't raise costs. In fact, it lowers costs, and the CBO says so. It doesn't add to the Federal deficit. In fact, it reduces the Federal deficit. I urge everyone to look at the facts closely whenever we hear statements made by anybody, including me. I urge people to listen to the words and read between the lines and see what is really going on. Like my father used to say: Don't believe everything you read and only half of what you hear. Take everything with a few grains of salt.

Will the Senator yield for a question?

Is it paid for?

That is a second question I would love to debate with the Senator. But on the first question only, the Senator admits it is paid for?

One more question. I think we all know the House has taken action on physician reimbursement, and the Senate will also do so before we adjourn. That is the so-called doc fix. That is a separate issue. That will be paid for. Putting the doctor issue aside, health care reform--and I say that because we take up the doc fix virtually every year. We don't take up health care reform every year. That is an entirely separate proposition, separate legislative endeavor.

If the Senator will bear with me and take the doc fix off the table for a second--we can address that later--health care reform--to use a 10-year number, or when you start in 2010 or in 2014, wherever you are starting--either there is $1 trillion or $2.5 trillion, depending where you start, not getting into how it is paid for. Is it paid for and therefore it is not deficit; am I not correct?

One more question on my time. Is it true there are no cuts in guaranteed beneficiary payments--none whatsoever--in this legislation--in guaranteed benefits?

Is it true those provisions are not guaranteed provisions? I am talking about guaranteed benefits that seniors expect to get when they go to the doctor, fee for service, expected benefits, under ordinary Medicare, not benefits that a private plan may pay in addition.

One more question. Does the Senator agree this legislation will extend the solvency of the Medicare trust fund for 5 years, and failure to pass this would mean the solvency of the Medicare trust fund would not be extended for 5 years?

Which colleague is the Senator asking that?

He does.

May I ask the Senator another question?

Then I have a question on the same subject.

Might I respond to the Senator?

Here is your opportunity; here is your chance.

It is on both sides. We have even time.

Yes. The basic question, obviously, is how to protect Medicare benefits. I think most of us would say how do we protect Medicare benefits and extend the solvency of the Medicare trust fund. I think we would all agree that excessive payments to providers would cause insolvency of the trust funds to come earlier rather than later. We all agree with that proposition.

The next question is, What would excessive payments to providers be? Do providers get paid excessively? I think that is an honest question we should ask ourselves in a way to help extend the solvency of the Medicare trust fund. In fact, in 1995, many Senators, especially on the other side of the aisle, did say just that, that we have to cut Medicare in order to save benefits. That was made by many Senators. I have them right in front of me, if anybody wants to hear them. I am not going to go through all of that, but it is the truth. That is exactly what we are doing in this bill. We are trying to help extend the solvency of the Medicare trust fund by cutting down on excessive provider payments from the Medicare trust fund.

How do we decide whether payments are excessive? That is the basic question here. All we can do is just give it our best shot, make our best judgment. I think it makes sense to look at the recommendations by outside independent groups, what they think. One is MedPAC, the Medicare Payment Advisory Commission. That is an outside group, as we all know, that advises Congress on Medicare payments. As Members of Congress, we are not totally competent to know exactly what dollars should go to which industry group. We have too many other obligations to think about. As Senators, we must be responsible to do the best we can. MedPAC has said these groups have been overpaid. And Wall Street analysts tend to agree. In fact, MedPAC said, with respect to Medicare Advantage, that they have been overpaid--I forget the exact amount but much less than the $118 billion reduction in this bill.

In fact, I totaled up and looked at the projected growth rate of providers--hospitals, nursing homes, home health, hospice, PhRMA, you name it--and on average their growth rate over the next decade is going to be 6\1/2\ percent. That is the growth rate of providers. We decided to trim that a little bit by 1.5 percent. So it is 5 percent. It is a 5-percent growth rate in an attempt to try to find the right levels of reimbursement to providers, which will also help extend the solvency of the Medicare trust fund.

When we talk to providers, they basically agree with those cuts. They basically agree. Why do they basically agree? They basically agree because they know that with much more coverage, with many more people having health insurance, they could spread out their business. They may lose a little on margin, but they can pick it up on volume. That is exactly what their business plan is under this bill.

Wall Street analysts say--I quote them--these industries are doing great, they are doing well under this bill. They are not getting hurt. So we do achieve a win-win--I don't like that phrase, by the way, but I will use it here--where the solvency of the trust fund is being extended and where reimbursement rates to providers are fair--not being hurt; it is fair. And that is why they want this bill, by and large.

Most groups tend to want this bill enacted because they know it is good for the country, it is good for the seniors, and it is good for them too.

No, no, no, I did not. With all due respect, I did not say that.

I talked about hospitals. I did not talk about doctors overpaid. If I may say to my friend from Tennessee, this legislation pays more to primary care doctors, a 10-percent increase in Medicare reimbursement for each of the next 5 years. I did not say ``doctors.''

If the Senator will yield for another question, might I ask my friend if it isn't also true that in the June MedPAC report it states that Medicare Advantage overpayments cost taxpayers an extra $12 billion?

Well, that is right, that is MedPAC. I think the point the Senator from Illinois is making needs to be underlined two or three or four times here--and the Senator from Connecticut has made it too-- and that is there is a huge distinction between Medicare and these private insurance plans.

It is not. It is a private plan.

What Medicare Advantage is overpaid--that is what these insurance companies are overpaid, and a lot of that goes back to the Part D drug bill and so forth--do those overpayments necessarily mean better benefits for persons who signed up for those plans?

If that is true, why might that be the case, just so people understand?

Does Medicare decide what the benefits will be for those folks?

The private insurance carriers.

You already said it, but I think it is worth repeating-- --

Most seniors, as they pay Part B premiums under fee for service, don't get any benefit whatsoever?

That is right. Higher premiums.

The figure I saw--I guess it is $90 a year they pay extra and get no benefit from it.

Will the Senator yield for a question?

I would like to hear you talk about the CLASS Act. I am no fan of the CLASS Act myself so why don't you proceed.

Mr. President, it has been a very interesting discussion, listening to the Senator from New Hampshire. Several points. One, the underlying bill is clearly not a net increase in government spending on health care. The numbers are bandied about by those on the other side-- $1 trillion, $2.5 trillion, et cetera. I do acknowledge and thank the Senator from New Hampshire for saying, yes, it is all paid for. He did say that. He did agree this is all paid for. So I just hope when other Senators on that side of the aisle

start talking about this big cost, $1 trillion, $2 trillion, whatever, that they do admit it is paid for. The ranking member of the Senate Budget Committee flatly said: Yes, it is all paid for. I would hope other Members on that side of the aisle heed the statement of the Senator from New Hampshire, ranking member of the Senate Budget Committee, for saying it is all paid for.

But don't take my word for it or his word. It is what the CBO says. In fact, let me quote from a letter to Senator Reid not too long ago:

The CBO expects that during the decade following the 10-

year budget window, the increases and decreases in Federal

budgetary commitment to health care stemming from this

legislation would roughly balance out so that there would be

no significant change in that commitment.

That is, a commitment to health care, to government health care spending, no change basically. It is flat. Although it is a little better than flat because the subsequent CBO letter has said the underlying bill achieves about $130 billion in deficit reduction over 10 years and one-quarter of a percent of GDP reduction in the next 10 years. The Senator from New Hampshire talks about large deficits this country is facing. That is true. Frankly, all of us in the Senate have a responsibility to try to reduce that budget deficit as best and as reasonably as we possibly can. Bear in mind, this underlying health care bill helps reduce the budget deficit. Sometimes people on the other side like to suggest that $1 trillion over 10 years will add to the budget deficit. Again, we have definitely established it does not add to the budget deficit at all, not one thin dime.

In addition, we actually reduce the budget deficit through health care reform, through this underlying legislation. We all know the Medicare trust fund is in jeopardy, in part, because baby boomers are retiring more but also because health care costs are going up at such a rapid rate. That is health care costs for everybody. It is health care costs for me, for every Senator, for every senior, for businesses. Let's not forget, we spend in America about 60 percent more per person on health care than the next most expensive country, about 50 to 60 percent more per person. The trend is going in the wrong direction. We are going to spend about $33 trillion in America on health care over the next 10 years. That is going to be somewhat evenly divided between public expenditures and private. Every other country in the world has figured out ways to limit the rate of growth of increase in health care spending. We haven't. We are the only industrialized country--in fact, developing country--that hasn't figured out how to get some handle on the rate of growth of increase in health care spending.

One could say: Gee, let's forget about it. Just let the present trend continue. We all bandy about different figures. One I am fond of at least remembering is the average health care insurance policy in America today costs about $13,000. If we do nothing over 8 years, it will be $30,000. That is a much higher rate of increase than income for Americans. It means the disparity between wages of the average American and what they are paying on health care will widen all the more if we do nothing. We have to do something. This legislation is a good-faith effort to begin to get a handle on the rate of growth of spending in this country.

The Senator from New Hampshire was being honest, frankly. Some on the other side are being not quite so honest. He is basically saying: Yes, it is true we are not cutting beneficiary cuts, although he talks about Medicare Advantage. Let me point out that there is nothing in this legislation that requires any reductions in any beneficiary cuts. In fact, guaranteed benefits under Medicare are expressly not to be cut under the express language of this bill. The portion we are talking about is Medicare Advantage. The fact is, there is nothing in this bill that requires any cuts at all in Medicare Advantage payments. Those Medicare Advantage payments are in addition to the guaranteed Medicare payments, such as gym memberships, things such as that which are not part of traditional Medicare.

Why do I say there is nothing in there that requires cuts for those extras? That is because the decision on what benefits or what extras Medicare Advantage plans have to give the guaranteed benefits, that is by law. But the decision as to what extras should go to their members is a decision based not upon us in the government, in Congress, not upon the HHS Secretary; it is based on the corporate officers of these companies. They are overpaid, Medicare Advantage plans, right now. Everybody knows they are overpaid. Even they, privately, will tell you they are overpaid. They are overpaid based upon legislation that Congress passed in 2003, the Medicare Part D, by setting these high benchmarks. They are overpaid. The MedPAC commission also said they are overpaid to the tune of about between 14 and 18 percent. So the reductions that are provided for in this bill, in Medicare Advantage plans, the effect of those reductions is up to the officers of those plans.

They could cut premiums people otherwise pay. They could cut benefits to help themselves, help their salaries. They could cut stockholders. They could cut administrative costs.

They can decide what they want to do. That is solely a decision of the executives of Medicare Advantage plans. Private insurance plans is what they are. They are private insurance plans, so there is nothing here that says the fringes, the extras, have to be cut at all. Those executives could keep those fringes and maybe have a little less return to their stockholders or maybe make some savings in their administrative costs, maybe not increase their salaries. There is nothing here that requires those fringes, those extras, to be cut, nothing whatsoever.

The Senator from New Hampshire says: Oh, it is about $400 billion to $500 billion of reduced payments to providers in this legislation. That is true. Well, let's look and see what the consequences of that are. First of all, that means the Medicare trust fund's solvency is extended. It is more flush with cash. I would think all Senators here would like to extend the life of the Medicare trust fund. A good way to do that is by what we are doing in this bill, saving about $450 billion over 10 years that otherwise would be paid to Medicare providers is not being paid, and those benefits inure to the trust fund.

There is no dispute--none whatsoever--that this legislation extends the life of the Medicare trust fund by another 5 years. That is because of those changes in the structure and also because there are no cuts in benefits. There are no cuts in benefits, I say to Senators. Although sometimes Senators on that side of the aisle like to either say or strongly imply there are cuts in benefits, there are no cuts in benefits. There are no cuts in the guaranteed benefits with the basic benefits, and there are no required cuts for the fringes or the extras because the officers can make that decision not to cut, if they want to. That is their choice, as I have explained a few minutes ago.

Let's look to see what the other side proposed not too many years ago back in 1997. They proposed cutting the Medicare benefit structure, cutting payments to providers, big time--big time. They proposed a 12.4-percent cut to providers back in 1997, when they were in charge. They did that in part to save the Medicare trust fund, to extend the life of the Medicare trust fund.

I have a hard time understanding why back then it was a good thing to do, which was about three times more of a cut--let's see, twice as heavy a cut to Medicare providers back then, in 1997, than it is today. Nobody over there has explained why it was the right thing to do back then but not the right thing to do today, when the goal is the same. The goal is the same; that is, to extend the solvency of the trust fund.

One could say--I think the Senator from New Hampshire did say--well, let's take those savings, which do extend the solvency of the trust fund, but not--he said--provide another program. I think he wants to use that to cut the deficit. That is what I think he wants to do.

That is a very basic, fundamental, values question I think this country should face; that is, do we want to set up a system where virtually all Americans have health insurance? We are the only industrialized country in the world that does not have a system where its citizens have health insurance--the only industrialized country

in the world. It is a very basic question. I think we should ask ourselves as Americans: In every other industrialized country, health insurance, health care is a right. That is the starting point. In every other country that has a health care system, health care is a right-- that everybody should have health care.

Of course, it is true, people are different. Some are tall, some are short. Some are very athletically endowed, some are not. Some are smart, some are not so smart. But health care does not care--that is a way to put it--whether you are dumb, smart, tall, skinny. It affects everybody; that is, diseases affect everybody, and everybody needs health care regardless of your station in life, regardless of your income, regardless of whether you are an egghead, you are brilliant, or an athlete. It makes no difference whatsoever. We are Americans.

I frankly believe other countries on that point have it right; that is, that they treat all their citizens basically equally because disease is indiscriminate--who is going to get disease--accidents are indiscriminate--who is going to get in an accident--and so forth. So we could take this $400 billion, $500 billion and reduce the deficit with it and forget any health insurance coverage. That would be an option. That is a legitimate question we could ask ourselves. I frankly think the better choice is to take that $400 billion, $500 billion, which does extend the solvency of the trust fund, and help set up a way, help set up a system so all Americans have health insurance. We do it in a way that reduces the budget deficit. We do it in a way that reduces the budget deficit in the first 10 years and also in the next 10 years.

I again repeat, if trimming the rate of growth of provider payments was OK back in 1997--that was twice as much as today back then to extend the solvency of the Medicare trust fund--why isn't it OK today to do half as much to extend the life of the trust fund, in this case for 5 more years, and at the same time help provide health insurance benefits for people who deserve it?

Let's not forget, hospitals want us to do this. They want everyone to have health insurance. Doctors want us to have a system where everybody has health insurance, whether it is Medicaid or it is private health insurance. All the providers want it. The pharmaceutical industry does, the home health industry does, the hospice industry does. The durable medical equipment manufacturers want it. They all want it because they know it is the right thing to do. They also know they are not going to get hurt.

I heard some reference here that some HHS actuary, commenting on the House bill, said, oh, gee, it might scare providers and whatnot, but we actually got subsequent information which showed that letter--that actuary admitted it is extremely variable, what he came up with. There are lots of factors he did not take into consideration. I also have statements from hospital administrators saying no way are they going to be allowed.

In fact, let's remind ourselves of this: It was not too many weeks ago, a couple months ago--remember that meeting--when all the health care providers and the insurance industry went to the White House? They were all over there. What did they pledge to President Obama to help get health care reform passed? That they would cut their reimbursements by $2 trillion over 10 years. They would cut. They agreed to cut their payments that Uncle Sam makes to them in the health care system by $2 trillion over 10 years. It was widely reported in the papers.

What did we do in this bill? We reduced the rate of increase in payments to providers, not by $2 trillion, not by $1 trillion, less than $\1/2\ trillion over that same 10-year period. So if they could commit back then to $2 trillion, you would think, my gosh, this is a quarter of that. That is not too bad and not going to hurt anybody, and providers are not going to be leaving.

I might add too, I have a letter from AARP to the majority leader dated today. It has been handed to me. In part it says:

The legislation before the Senate properly focuses on

provider reimbursement reforms. . . . Most importantly, the

legislation does not reduce any guaranteed Medicare benefits.

This is a letter today from the American Association of Retired People. I will re-read that portion. It is addressed to Senator Reid:

The legislation before the Senate properly focuses on

provider reimbursement reforms. . . .

And, man, we need about a week or so to talk about all the reforms in this bill that are so important so we have a better health care system focusing more on quality than we currently do in the United States system. Again:

Most importantly, the legislation does not reduce any

guaranteed Medicare benefits.

In the letter they also say:

AARP believes that savings can be found in Medicare through

smart, targeted changes aimed at improving health care

delivery, eliminating waste and inefficiency, and

aggressively weeding out fraud and abuse.

That is important. It is very important. I might add, too, that every person today who pays a Part B premium--every American today--every senior today who pays that quarter, that 25 percent of Part B today, pays also for the waste that is in the system today, especially under Part B. So if we get the waste out, we also will be able to reduce that Part B premium payment that seniors have to pay too. I think that is a good thing.

So the more you dig into this bill, the more you see the good features. I do not think all the good features have been pointed out in this bill. One of our jobs here is to point out what they are, so when this legislation passes--mark my words, this legislation is going to be enacted. It is going to be enacted, I will not say exactly when, but certainly, if not this month, it will be signed by the President either this month or next month--then Americans are going to start to see: Oh, gee, there is a lot in there that is good. I didn't know about that. That is good. I like that. It may not be perfect, but they started in the right direction. That is pretty good. They are going to like it.

I hear all these references to polls around here, and that is because of all the confusion, in part. But once it is passed and people look to see what is in it--they will look to see what is in it because that is the law. They are forced to look to see what is in it because that is the law.

I know some of my colleagues on the other side of the aisle may say: Yes, when they look to see what is in it, they will see how bad it is. I disagree. That is not my view. My view is, the more this legislation is subjected to the light of day, the disinfectant of sunshine, which shows what is in this bill, the more people are going to say: Hey, that was a good thing they did back then in December or January.

I yield the floor.

As soon as I get the page number, I guess I would like to ask the Senator from Oklahoma a question.

What page?

I don't have it with me right now, but there are no required reductions in fringes or extras--

Fringes, such as gym memberships, and extras such as that. The bill basically provides that there be no reductions in guaranteed Medicare payments. There is a long list of what guaranteed Medicare payments are.

Even the Medicare Advantage companies, which are private companies with officers and they have stockholders--they have to report to their board of directors, and they have all these administrative costs, very huge admin costs. The reductions to Medicare Advantage--the application of reductions to Medicare Advantage plans are at the discretion of the officers. The officers can decide they are not going to cut the fringes; that is, the fringes and the extras that are beyond, in addition to the guaranteed Medicare benefits.

If an officer wants to, it is his discretion, I am assuming--

Will the Senator yield?

It is true--first of all, we need to back up. Isn't it true that the MedPAC commission came to the conclusion that the Medicare Advantage plans are overpaid?

It is also true that it is their recommendation that the Medicare plans overpaid by the amount of 14 percent.

That is true. They are overpaid.

If they are overpaid, doesn't that necessarily mean there are reductions in payments attributable to each beneficiary by definition?

If they are overpaid--

Absolutely. In 2003, I made the mistake and agreed to give the Medicare Advantage plans way more money than they deserved. And as the Senator from Oklahoma has said, they are overpaid.

Mr. President, I ask unanimous consent that Senator Whitehouse, Senator Stabenow, Senator Dodd, and I be allowed to engage in a colloquy.

Mr. President, who has the floor? We are all talking.

I ask my colleagues, is it not true that basically in America, although all of America spends about $2.5 trillion on health care, basically it is 50/50. It is 41 or 42 percent public and about 60 percent private. We in America have roughly a 50-50 system today; is that right?

This legislation before us basically retains that current division. What we are doing is coming up with uniquely American ideas. We are not Great Britain, France, or Canada. We are roughly 50-50--a little more private in fact. In 2007, it was 46 percent public and about 54 percent private. Roughly, that is where we are. It might change ever so slightly. But we are not those other countries, we are America.

This legislation before us maintains that philosophy; is that correct?

But isn't that a pretty good system--don't put too many eggs in one basket? Doesn't each keep the others on their toes a little bit?

Doesn't this legislation provide for more competition than currently exists?

For example, with exchanges, with health insurance market reform and with the ratings reform.

I ask my colleagues, is there anything in this legislation which will interfere with the doctor-patient relationship; that is, to date people choose their own doctors, whichever doctor they want. They can, by and large, go to the hospital they want, although the doctor may send them to another hospital. Is there anything in this legislation that diminishes that freedom of choice patients would have to choose their doctor?

What about the procedures doctors might want to choose for their patients? Is there anything in this legislation which interferes with the decision a physician might make as to which procedure to prescribe, in consultation with his or her patient?

I might ask my friend--that is very true--Could he explain maybe how doctors may be, in this legislation, empowered to have better information to help them provide even better care? What are some of the provisions?

I think it is important not to overpromise because some of these initiatives, some of these programs will take a little time to take effect. In fact, some of the provisions do not take effect for a couple, 3 years. But still, wouldn't my colleagues agree that some of these are going to probably yield tremendous dividends in the future, especially generally the focus on quality, not outcomes, reimbursing physicians and hospitals based on quality, not outcomes, the pilot projects, the bundling, the counter care organizations and other similar efforts in this legislation. One of the two or both may want to comment on that point. I think it is a point worth making.

Very.

Right. Some people are worried, perhaps, gee, there they go back there in Congress. They talk about waste--which is good; we want to get rid of waste. But then when they talk about waste, they talk about cutting out the waste, some think: Gee, if they are cutting out the waste and they are cutting health care reimbursements, gee, won't that hurt health care in America? Won't that harm health care in America? Won't that reduce quality? If they are cutting so much, $600 billion, $700 billion, $800 billion--that is a lot of money--aren't they going to start cutting quality health care in America?

I see my good friend, the chairman of the HELP Committee, on the floor. He may want to join in this discussion as well, adding different points as to why the legislation we are putting together increases quality, does not cut quality, but it increases quality at the same time it reduces waste. I wonder if my colleagues might comment on all of that because it is an extremely, I think, important point to drive home our legislation improves quality health care.

I think my colleague is exactly right. As he was speaking, I was thinking of that article a lot of us have referred to often, the June 1 New Yorker article by Atul Gawande, comparing El Paso, TX, and McAllen, TX. They are both border towns. In El Paso, health care expenditures per person are about half what they are in McAllen. And yet the outcomes in El Paso are better than they are in McAllen.

One might ask: Why in the world is that happening? Why is there twice as much spent in McAllen than El Paso and the outcomes are different? The answer is we have a system which allows the McAllens in the system, that allows payment in basic quantity and volume as opposed to quality.

I believe it depends on the community what the culture is. Some communities have a culture of patient-focused care. The current system allows that, but, unfortunately, if the culture in the community is more to make money, our reimbursement system today allows for that as well. So I think one of the things we are trying to do is to get more quality in the system--reimbursement to pay doctors and hospitals--more quality, as you have said--and that is going to even out a lot of the geographic disparities that have occurred in the country over time and so the quality will increase and the cost and the waste will decrease.

There is no doubt about that. In fact, it is interesting the Senator mentioned his name because not too long ago I asked him that question. I said: Why, Dr. Berwick, is it that in some communities they get it and some they do not? His answer was that sometimes there is somebody--maybe it is a hospital or someone who is a pretty dominant player--who kind of starts it out and gets it right, and that is true.

He invited 10 integrated systems to Washington, DC, to kind of talk over what works and what doesn't work.

These are not the big-named institutions; they are the lesser named institutions. In fact, one of them I can probably say is the Billings Clinic, in Billings, MT--not too widely known, but they participated last year--the same process and integration with the docs, the acute care, and the postacute care. They have significantly cut costs, they have significantly improved the quality, and they are very proud of what they have done.

I have very direct experience in this. My mother was in the hospital 3 years ago--in another hospital, not the Billings Clinic--and there was no discharge plan. There was no way to help deliver health care for her when she left the hospital and went into a rehab center--sort of a nursing home. Sure enough, she didn't get the proper meds, she didn't get the proper attention, the doctor did not see her every day or after that, and, lo and behold, she had to be readmitted to the hospital. She had a gastrointestinal issue, and, sure enough, they took care of her back in the hospital. But once she was discharged, they did it right. They improved upon the mistakes they had made.

So I saw it firsthand, and it irritated the dickens out of me, frankly, in seeing how they did not pay sufficient attention to my mother. If this happens to my mother, my gosh, I bet it is even worse in lots of other situations.

Well, she is now home and getting great attention. I made sure of that.

An example of that. I was talking to the head of Denver Health. It is an integrated system. I have forgotten the name, but she was so enthusiastic about the integration she performed with Denver Health. I will give you one small example, and it is one you just mentioned. She said: We have patients here--heart patients--and when they are discharged we ask them: Are you taking your meds? Are you controlling your blood pressure? Are you taking your medication to control your blood pressure?

They say: Oh, yeah, yeah, yeah, I am taking my meds.

She says: Well, why is your blood pressure so high?

The response is: Well, I, I, I. Because they are

integrated, they check with their pharmacy, which is part of

their system, to check the refill rate of the patients. Sure

enough, they find their patient's refill history shows they

were not taking their meds. So they get the patients back and

they say: You are not taking your meds.

They say: Oh, I guess I wasn't.

They tell them: We are checking on you.

So, sure enough, they take their meds, and they have a much better outcome, generally, with their cardio patients because of that integration.

Absolutely.

I don't know how much longer my colleague wanted to speak, but some time ago I know Senator Hatch wanted to speak at 5 o'clock, so I am trying to be traffic cop here.

Mr. President, today I wish to speak about the life lessons we learn from participating in athletic activities and from the coaches who teach our young athletes. Michael T. Powers, author of many inspirational books once said, ``High school sports: where lessons of life are still being learned, and where athletes still compete for the love of the game and their teammates.'' High school sports are a way of life across Montana and they create an important sense of community in small towns and cities all over Big Sky country. In many areas across the state, small high schools will pool their resources to field football teams each fall; many play six or eight man games.

This year Ed Flaherty, a native Montanan co-authored the book ``Coached for Life'' about the experience he and his teammates had on the State champion Great Falls Central High School football team in 1962. I was inspired by the stories of these young men and how the lessons learned on the field from their coaches shaped who they became as people and their experiences later in life.

The young men that made up Great Falls Central's 1962 Championship squad truly embody the best of Montana ideals and values, like hard work and taking responsibility. They labored tirelessly both on and off the field and achieved not only athletic glory, but also learned the value of a good education and how to be role models and ambassadors for their school. Great Falls has always been a working class town and many families made significant financial sacrifices to allow their children to attend Great Falls Central, a private Catholic school. Coaches Bill Mehrens and John ``Poncho'' McMahon, reminded the players each day that playing football at Central was a privilege and that they had a responsibility to their teammates, their school, and the community to give it their all on each and every snap on the practice field, in the game, and in the classroom. No doubt the coaches pushed these young men each and every day, they did it to instill discipline and to make them the best they could be.

The 1962 season was a special one for Great Falls Central. The goal of the team was to win the State championship. A year earlier, the coaches drove some of their players north 115 miles to Havre to watch the State championship game, not only to scout two of the best teams in the State but also to witness a championship win. The Central players took it all in and knew they wanted to be the ones holding up the trophy the following season. The Mustangs achieved that goal, making it through the 1962 season undefeated and beating their rival, the defending State champions, Havre High 34-6 in the Montana Class A State championship game in front of more than 5,000 elated fans on their home field.

Having gone through this experience, the men later in life were able to rise up against the many challenges that were thrown their way. At a team reunion in 2002, 40 years after their championship run, the players and coaches got together to reflect and share their life stories. Some have gone on to be teachers and coaches, passing on the life lessons they learned from Mehrens and McMahon. Some, like Ed Flaherty, have achieved successful careers in business and in turn gave back to their communities. Some served their country heroically in the military. All have taken the lessons they learned from the fall of 1962 and have helped their communities and become leaders. Ed Flaherty has compiled these stories in his book and brings to life that amazing season and what it truly means to be coached for life.

Madam President, I yield myself 1 minute. Very much straight to the point here, there has been some discussion about CBO's assessment on the health care premiums. The letter was out yesterday. That letter shows that for all Americans--all Americans--premiums will be lower. They will be modestly lower to those larger employers. We have a range between those small businesses of between a 1-percent reduction and a 2-percent increase, and for the individual market there is more variation because there is much more variation today currently in the individual market.

Those who purchase in the individual market will be getting a lot better quality of insurance than they are getting today--much better. About 60 percent of those in the individual market will find that their premiums are actually lower after the tax credit/subsidies are taken into consideration.

So netted all out together, all Americans are going to see their premiums are lower for what they get today. About 7 percent will see an increase, but they are getting better coverage than today--quite a bit better coverage. On a net basis, basically, bottom line, everyone were will see his or her premiums lower. For the 7 percent that are not lowered, they will get a lot better quality of insurance. That will more than offset the increase in premium. That is what that CBO letter says. I urge all folks who are interested to read that letter.

I have one other minor point on the so-called Cadillac plans. CBO said that those who receive Cadillac plans will find their premiums reduced, not increased--I think it is by about 6 or 7 percent. That, too, is very important. There has been a lot of discussion about the effect of premiums on Cadillac plans. CBO says those premiums will be reduced.

My minute is probably up. I wish to use the last seconds to just say that the net, all the way across the board, CBO says premiums will be reduced when you take subsidies into consideration and compare the plans people get today with what they would otherwise get in the future, the quality of coverage.

Mr. President, I ask unanimous consent that the next four Republican speakers to be recognized be Senators Johanns, Roberts, Hutchison, and Cornyn and for the Democrats to speak in an alternating fashion, with the next Democrats being Senators Murray and Cantwell to speak on the tragic shootings in Washington, and that following Senator Roberts, I be recognized.

I am sorry. I think Mr. Roberts is to be recognized.

Mr. President, I wish to once and for all lay to rest this false claim that the pending bill is going to ``hurt seniors'' and is going to hurt providers; it is going to be this long parade of horribles that the other side likes to mention. It is totally, patently untrue, the claims they are making.

No. 1, all the crying allegations on the other side that the underlying legislation cuts Medicare, it cuts Medicare, it cuts Medicare--that is what they say. What they do not say is it does not cut Medicare guaranteed benefits. It doesn't cut benefits. It does reduce the rate of growth that hospitals would otherwise receive. It does reduce the rate of growth that medical device manufacturers might receive. All that is true. So it is true it is cutting the rate of growth of Medicare providers. It is not true that this legislation cuts Medicare benefits. That is not true. The other side would like you to believe that is true by using the words

they choose. By saying ``cutting Medicare,'' they want you to think that is cutting Medicare benefits.

But it is not cutting Medicare benefits. Rather, the underlying bill reduces the rate of growth of government spending on providers, on hospitals, home health, hospice--lots of other providers. That is what is going on here. Don't let anybody fool you. This bill does not cut Medicare benefits. It does not. But it does reduce the rate of growth of providers.

Why are we doing that? First of all, most of these providers, virtually all the providers say--gee, we don't like our rate of growth, the Federal dollars coming to us, cut, but they will go along with it. They are OK with it. Why are they OK with it? Why is the American Hospital Association OK with reducing the rate of growth of hospital payments by $155 billion? Why are they OK with that? They are OK with that because they are going to make it up on volume. This legislation provides coverage for many more Americans. They are going to have health insurance. Americans who do not have health insurance now often have to go to the emergency room of the hospital, the hospital has to provide the care, it is uncompensated care--nobody is paying for those hospital benefits--and that cost is transferred on to private health insurance premium holders. They have to pick it up. On average, that is about $1,000 per family per year.

No. 1, let me repeat, there are no cuts to Medicare benefits. There are reductions in the rate of growth to Medicare providers--which the providers agree with, by and large. I won't say totally, I wouldn't stand here and say they are jumping up and down and they are enthusiastic about it, but I am saying they realize they are not getting hurt. They are going to do OK. They are going to do OK because they are going to make up in volume what they might otherwise lose. That is a very important point for people to understand.

Second, if you listen to the other side, what they would have us do is virtually do nothing. What does doing nothing mean? Doing nothing means the solvency of the Medicare trust fund is just over the horizon. This legislation extends the solvency of the Medicare trust fund another 4 to 5 years. Man, if I am a senior--I am about to be a senior--I would sure like the Medicare trust fund to be solvent. I would like that very much. This legislation extends the solvency of the Medicare trust fund by another 4 to 5 years, to about the year 2017. So without this legislation, the actuaries say the Medicare trust fund is going to become insolvent 5 years earlier, 2012, somewhere there. That is not many years from now; not many years at all. So it is very important we extend the solvency of the Medicare trust fund.

You might ask why is the Medicare trust fund in a little bit of jeopardy? Why is that? The very basic reason is because health care costs are going up at such a rapid rate in America. Our health care costs are going up by 50 or 60 percent more quickly than the next most expensive country. We already are paying per capita 50 percent or 60 percent more than the next most expensive country. So there is a whole host of things we are doing in this legislation to make sure we have some limit over our health care costs.

I realize I misspoke earlier. Currently the Medicare trust fund is due to be insolvent about the year 2017. This legislation extends the solvency of the Medicare trust fund to the year 2022. The principle is the same, just the 5 years is tacked on a little later period of time rather than upfront.

But we are doing a whole host of things in this legislation to reduce the rate of growth of health care costs to people in this country. It is health care costs which are driving up the Medicare trust fund costs so we are doing all we can to extend the solvency of the Medicare trust fund.

People are saying the Medicare trust fund is getting insolvent because baby boomers are retiring, and that will increase the pressure on it. But the Congressional Budget Office did a study 6 or 8 months ago that said about 70 percent of the additional cost of the Medicare trust fund is due to cost increases, it is not due to more baby boomers retiring when they reach the age of 65.

What do some of the groups say about this legislation? Let me say what AARP says. We have a chart here which indicates what the American Association of Retired People says about the underlying bill. If it was cutting Medicare as the other side says, you would think they would not like this bill. You would think they would have problems with it.

AARP has not totally endorsed this bill, but they don't have problems with it because they know we are doing the right thing. What do they say? AARP says:

Opponents of health care 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 what the AARP says, referring to the distortions, misrepresentations, and untruths, trying to scare seniors, mentioned by opponents of this legislation.

Here is another AARP quote. This is this month:

The new Senate bill makes improvements to the Medicare

program by creating a new annual wellness benefit, providing

free preventive benefits, and--most notably for AARP

members--reducing the drug costs for seniors who fall into

the dreaded Medicare donut hole, a costly gap in prescription

drug coverage.

That is a very important point. This bill not only does not cut benefits, it increases benefits for seniors. A big one is referred to right there and that is the so-called doughnut hole, the gap in coverage under the prescription drug program. This legislation in effect says that seniors now who have $500 of their drug benefit, prescription drug benefits paid for when they are in that doughnut hole period, and add to that this bill also says it is all paid for, at least for 1 year, in this doughnut hole. We have to worry about that in subsequent years, but this bill improves the benefits that seniors will get, not take away benefits as the other side would imply.

It is true that private programs, such as Medicare Advantage, are reduced from what they otherwise would be, just as hospitals are reduced in payments from what they otherwise would get. I have a chart here. Let me point out the next chart here, if I could, which shows that the provider groups, hospitals, et cetera, are actually going to do OK under this legislation. What does this chart show? This chart shows that Medicare spending will continue to grow under this legislation. It will grow, and grow by a lot. Here, in 2010, it is $446 billion and you see a steady growth through the 10 years of this bill.

I might say parenthetically, one of the previous speakers said rural health care is going to be hurt, rural hospitals are going to be hurt in this legislation. I do not think that is entirely true. I have a lot of hospitals in my home State of Montana, rural hospitals. They are not upset with this legislation. They say it is OK. They approve it.

In addition, there are no cuts to critical access hospitals. In rural America most of those hospitals are critical access hospitals. So they are going to be OK.

Basically, if we did not pass this legislation, these provider groups--hospitals, nursing homes, home health, hospice, Medicare Advantage, even Part B Medicare improvement--would all increase by about 6.5 percent over the decade. Under this legislation they all increase by about 5 percent over this decade, with a 1.5 percent cut which they basically agree to.

I want to make that point clearly. We are not cutting Medicare. We are not cutting Medicare benefits, but we are reducing the rate of growth of Medicare spending.

Another point I want to make, if I may, is there is nothing new here. Many of the Senators who are advocating killing this bill made the opposite statement not too many years ago. What did they say? They said: You have to reduce the rate of growth in Medicare spending in order to save Medicare benefits. That is what they said a few years ago, exactly what they said. Let me read:

We propose slower growth in Medicare. Medicare would

otherwise be bankrupt.

They are standing on this floor making the opposite statement today, the exact opposite statement today, trying to scare people to kill the bill.

Here is another Senator. I will not embarrass them by giving their names,

but they are Senators who currently serve in this body.

We do heed the warning of the Medicare Board of Trustees

and limit growth to more sustainable levels to prevent

Medicare from going bankrupt in 2002. That is what is

necessary to ensure that seniors do not lose their benefits

altogether as a result of bankruptcy in 7 years.

One Senator said that. When? About 14 years ago. Exact same thing that is going on today.

We know, experts know that if we are going to save Medicare benefits, we have to stop overpaying some of the providers, hospitals and so forth. We are overpaying them.

Let me tell you one small example of how we are overpaying them. Did you know that the updates--the fancy term for paying more for hospitals and so forth--did you know they don't take productivity into account when they make these update recommendations? The recommendations are basically made by an organization called MedPAC. MedPAC is a nonpartisan organization composed of doctors and experts that advise Congress on what the payment updates--what the payment increases should be for different groups over the years. We in Congress basically look at them. We try to decide what makes sense, what doesn't, and so forth. But MedPAC has said that this is what we have to do. We have to slow the rate of growth in some of these providers because they are getting paid too much. They are getting paid more than they need to be paid.

I repeat: We are still going to allow 5 percent growth for all the providers over the next 10 years. None of them are really crying wolf, I might say. That is the main point I wanted to make.

I mentioned what AARP is saying. Let me mention the American Medical Association:

[We are] working to put the scare tactics to bed once and

for all and inform patients about the benefits of health

reform.

That is the American Medical Association. They are referring to the scare tactics of the other side. The AARP and the American Medical Association and others know that no senior will see a single reduction in their guaranteed Medicare benefits under this bill, not a single one.

I might also say that this bill would reduce premiums seniors would have otherwise paid. Much of those savings to seniors comes from eliminating massive overpayments to private insurers; that is, private companies such as Medicare Advantage.

A small point here. When seniors hear the words ``Medicare Advantage,'' they tend to think that is Medicare. It is not. It is a private company. Those are private companies. They were basically enhanced. Under the 2003 Medicare Part D legislation, they were given a lot more money to encourage them to have competition in rural areas. It turns out we gave them way too much additional money. They know it. This legislation is trying to cut back on the excess they were provided back in the year 2003. The cut is about $118 billion over 10 years. I don't have with me how much is remaining. But that 5 percent figure I gave you of growth, that includes Medicare Advantage.

I mentioned already that this legislation would reduce prescription drug costs. That doesn't sound like a benefit cut to me; that sounds like an additional benefit for seniors. We also provide for new prevention and wellness benefits in Medicare. That is an addition. That is not a cut. That is an addition. We are also helping seniors stay in their own homes, not nursing homes. That is a benefit.

It is important to point out here that the opponents of health care reform do not have a plan to protect seniors and strengthen the Medicare Program. They say don't do what they said a few years ago. They say: Commit the bill, do nothing. They say: Go back and start from scratch again. That is basically what they say. If you listen to the music as well as the words, if you read between the lines, basically they are saying: Kill it. Don't do it. That doesn't make sense.

That is what they are saying. I hate to say this because I tend to be a pretty nonpartisan kind of a guy. But these are scare tactics. They are not truths. Sometimes you have to call a spade a spade, and that is exactly what is happening here.

I might say that MedPAC, the outfit that advises us, is nonpartisan. They can't help us decide what to do here. They think Medicare Advantage plans are overpaid by 14 percent. In addition, a typical couple will pay $90 more per year in Part B premiums to pay for Medicare Advantage overpayments even if they are not enrolled in these plans. That is not right.

Medicare home health providers--I gave that list earlier. One small part of that is Medicare home health providers. They have an average margin of 17 percent. That is a little high.

If we are trying to protect Medicare benefits, we have to make sure we are not overpaying the Medicare providers. That is just common sense. It is the right thing to do. So many seniors just need help with their Medicare benefits.

Nursing homes are making profits of 15 percent off of Medicare. In my judgment, that, too, is unacceptable. We have to bring those down within reason.

We have an obligation. This is a government program. We have an obligation to taxpayers to make sure we are not overpaying hospitals and providers. We have to do right by them, make sure they are doing OK, but just not overpay. That is a tough line to draw sometimes. It is a judgment call. But that is what we are doing here.

In addition, the Office of Inspector General has found rampant fraud and waste and abuse in the Medicare Program. There is a lot of fraud and waste in the Medicare Program. The last figure I saw was about $60 billion in fraud in Medicare--providers, frankly, just ripping off taxpayers and seniors. We have added additional provisions in here to outlaw that fraud--additional screening, additional certification, additional ways to make sure that Medicare does a better job, that CMS does a better job in knowing which payments to providers are right and which are not right.

What is the real impact of the Medicare policies here? Let's be clear: The real impact of these policies, even with the Medicare changes in the bill, overall provider payments will still go up. I don't want to beat that horse too much, but I want to make it clear. We are not cutting benefits. We are reducing the rate of growth of spending for health care providers, hospitals, and nursing homes, but we are reducing it in a moderate way. We are not reducing it by too much. As this chart shows, those providers still get at least a 5- percent net increase in payments over the years, and the groups themselves have not really complained about them. Take the pharmaceutical companies, hospitals, nursing homes, home health, hospice--they are not crying crocodile tears because they know they are going to do better under health care reform.

Remember that famous meeting down at the White House not too long ago. The industry came in and talked to the President. Remember what they pledged, all these providers, how much they can cut reimbursements to them? This is including the insurance companies, hospitals, and everybody. They said they would cut $2 trillion over 10 years--$2 trillion. This legislation doesn't come close to cutting $2 trillion. I think the figure is about $400 billion. That is not $2 trillion, that is $400 billion. So we are not hurting them that much. We are not hurting them, frankly. They are doing OK.

I have quotes from hospital associations. This is from Sister Carol Keehan, president of the Catholic Health Association:

Clearly, the Catholic Health Association thinks the

possibility that hospitals might pull out of Medicare . . .

to be very, very unfounded.

I have heard the claim over here that this legislation is going to cause providers to pull out of Medicare. That is totally untrue. I have so many quotes here from people in the hospital industry who believe this is OK. They are not going to pull out.

Chip Khan, president of the Federation of American Hospitals:

Hospitals will always stand by senior citizens.

I also know some providers are going to do very well under this reform legislation. Wall Street analysts have suggested that many providers, including hospitals, will be ``net winners,'' according to the basic feeling among Wall Street analysts. Under our bill, they estimate hospital profitability

will increase with reform because more and more hospital patients will have private health insurance.

Nobody is going to pull out. They are not going to cut Medicare benefits. It is true that there is a reduction in some of the private plan nonguaranteed benefits companies would give to seniors at the expense of private patients. That is true.

MedPAC has said it should be cut. MedPAC has said it should be cut more. We are giving these plans a break by not cutting them by what MedPAC says they should be cut.

Again, the reductions in this bill--for the providers, not beneficiaries--are far less than the health care industry itself said it could save over the next decade. A reminder: They pledged to save $2 trillion over 10 years. Under this legislation, they are going to be hit for $400 billion.

I mentioned before that the other side has often said this is exactly what we to have do, although today they say: No, no, no. I am not quite sure what the difference is between a few years ago when they said this is what we should do. Perhaps they can explain that.

I might mention, too--and this is very important, although we tend to lose sight of it--under this legislation, we provide delivery system reform.

There is a lot of waste in our health care system--estimates are 15, 20, 30 percent waste in the American system. Why is there so much waste, which means seniors are not given the benefits they should receive, which means private patients generally aren't getting the benefits they should receive because of all the waste? The waste is basically because of the way we pay for health care. We pay on the basis of quantity. We pay on the basis of volume. We do not pay on the basis of quality. To state it differently, a hospital tries to do the right thing, doctors try to do the right thing. They are paid on the basis of how many procedures they provide, basically, not outcomes, not quality. That is the basic root that has caused a lot of the waste in the current American system.

Health care is provided for differently in different parts of the country. The fancy term is ``geographic disparity.'' Health care in one community is practiced one way. Health care in another community is practiced another way. They are very different.

Many of us have read the June 1 New Yorker article written by Dr. Gawande comparing El Paso, TX, with McAllen, TX. I see the two Senators from Texas on the floor. Perhaps they can help us elucidate what is going on in El Paso and what is going on in McAllen. In El Paso, the cost of health care is about half per person what it is McAllen, another border town. Spending per person in El Paso is about half what it is in McAllen. Yet the outcome; that is, how well the patients do, is a little bit better in El Paso than it is in McAllen. Why? According to the author of the article, it is because of how medicine is practiced, what is the ethic, what is the sense in El Paso regarding health care and what is it in McAllen regarding health care. It may be dangerous for me to say so, but according to the author, his conclusion is that in El Paso, it is because the care is more patient centered, it is coordinated care, it is less on making a buck; whereas in McAllen, it is less coordinated care, more specialties in hospitals, a little bit more providers wanting to go make a buck.

The main point is that medicine is practiced so differently all over the country. There are geographic disparities. In Northern High Plains States, it is less spending per person and the outcomes are terrific. In some of the Sunbelt States--and I don't want to step on the toes of any Senators from Sunbelt States--there is more spending and the outcomes are worse. It is just because it is based on volume and quantity, not based on quality.

This legislation starts to put in place ways to move toward reimbursing based on quality, not volume. That, paradoxically, is going to result in lower costs and higher quality--lower costs but higher quality. Virtually all the folks in the health care community--the doctors, hospitals, and administrators I talk to--virtually all agree-- I will be very conservative--80 percent agree, 85 percent agree, this is the direction in which we have to go.

This legislation goes in that direction. Failure to pass this legislation, which the other side wants, means we do not do any of that. It means we do not start putting in place ways to more properly reimburse doctors and hospitals and other health care providers.

This bill includes those patient-centered reforms I just mentioned. What are they? They include accountable care organizations, bundling is another concept, reducing unnecessary hospital readmissions, creating innovation centers. This bill starts to do that.

There is something else this bill does but which some on the other side get all exercised over and which I think they get exercised over improperly; that is, ways to start to compare one drug versus another, compare one procedure versus another, one medical device versus another. We have to start doing more of that with a nongovernment agency, with a private-public agency that works together so it gives good, solid information so we have more evidence-based medicine in America.

Right now, a lot of docs want to do the right thing, but what they do depends on the drug rep who comes in their office and starts peddling a certain drug. Docs feel uneasy about that, they do not like it, but they are so busy they see so many patients, it is hard to keep up to date. So we are trying to help them keep up to date with evidence-based medicine, and with a lot more health IT, health information technology, so they can get access to the best evidence through these various organizations.

There are just so many reasons this legislation is so important. I personally believe we have to move a bit toward what is called integrated systems. We hear about Geisinger, the Mayo Clinic, the Cleveland Clinic, Intermountain Healthcare. There is some home health out in Seattle where doctors and hospitals and nursing homes and pharmacists are more integrated, and that, therefore, cuts down on cost, increases quality. It is more patient centered. It is more care coordinated. This legislation helps us move in that direction.

We are just trying to get started with this legislation, get started in doing some of the right things we know we should do. We do not have all the answers. Nobody has all the answers. But if we get this legislation passed, in the next couple, 3 or 4 or 5 years, working with the basic underpinnings of this legislation, we are going to help correct some mistakes. We are going to see some new opportunities. We are going to be working on getting health care costs down, which we have to begin doing to help our people, help our companies.

We are going to work to get more coverage so more people have health insurance. It is an embarrassment today. It is an absolute embarrassment that the United States of America, an industrialized country, does not provide health insurance for its people. It is more than an embarrassment. It is a travesty. It is a tragedy. It is just wrong, it is morally wrong.

So this legislation gets us moving on the right track. It helps Medicare beneficiaries not hurt them, as the other side would like you to believe. It does not unnecessarily harm doctors and hospitals. They kind of go along with this. They kind of know it is the right thing to do. They are still getting big increases in payments, and there are other reforms here which I have not the time to mention tonight. But I strongly urge us to say: Hey, this is the right thing to do. Let's get started. Let's pass this legislation and certainly trounce this committal motion to stop what we are doing. It is not right to stop this. We are getting started. Let's keep going.

I yield the floor.

Mr. President, I didn't think there was a time agreement here.

Mr. President, I understand we have several Senators who wish to speak. First, the Senator from Michigan, Ms. Stabenow, then Senator Hatch; Senator Cardin would be third. I don't want to tread on any toes. I say to Senator Cardin, there is a little bit of time constraint.

We are alternating. We are respecting the alternating back and forth.

The Senator from Michigan is next, Ms. Stabenow.

Mr. President, as I understand it, there are a couple Senators left, besides myself, Senator Sessions and Senator Burr. There may be others, but I see them at the moment.

America's health care system is in a crisis. It is a crisis not just for the 46 million Americans who lack health insurance; it is also a crisis for those who have health insurance but are worried they cannot afford to keep it. It is also a crisis for those who are underinsured and those who have poor health insurance.

Rising health care costs affect families and American businesses. That we know. Health insurance premiums continue to outpace wages and inflation by a large margin. Between 1999 and 2008, premiums for employer-sponsored health benefits more than doubled. In that 9-year period, they increased 117 percent for families and individuals, and they increased 119 percent for employers. In each case, both for families and for employers, health insurance premiums doubled. Clearly, that is outpacing wages. I think the margin is 5 or 6 to 1, with premiums going up compared with wages for Americans.

Health care coverage for the average family now costs more than $13,000 a year. If the current trend continues, by 2019, the average family plan will cost more than $30,000. That is over a 10-year period--from $13,000 for the average family today to $30,000 that family will pay then.

Annual health spending growth is expected to continue to outpace average annual growth in the overall economy by 2 percent over the next 10 years. Health care spending is going up faster than the economy is growing. Add to that the insult, frankly, that this year alone not only would health spending increase 5 percent but GDP is expected to decrease two-tenths of a percent. So the gap is widening even further.

Americans spend $4.5 million in health care every minute of every day. Think of that. We, in America, spend about $4.5 million in health care every minute. That is $2.5 trillion a year. It is pretty hard for anybody to get his or hands around 1 trillion, but we are talking about $2.5 trillion that Americans spend on health care every year. Without reform, health care expenditures will increase to $4.4 trillion in just the next 9 years. That would be more than one-fifth of our economy. So health care is taking a bigger and bigger bite out of our economy. These are not just numbers.

Every 30 seconds, another American files for bankruptcy after a serious health problem. Think of that. Every year, about 1.5 million families lose their homes to foreclosure. Why? Because of unaffordable medical costs. In America, nobody should go bankrupt because they are sick. That is immoral.

These numbers tell us what we have to do. We have to do two things at once. First, our health care reform bill must provide health care for millions of Americans who today don't have health insurance. At the same time, we must reduce the rate of growth in health care spending. We must do both. To be successful, health care reform must rein in the cost of health care spending, and we must succeed. Millions of Americans depend on it.

Our plan is to reduce the Federal budget deficit by $130 billion over the next 10 years. Think of that. Many have said an economic recovery is through health care reform. We have to get control of our deficits. One way to do that is to get control of our health care spending. The bill before us now reduces the deficit by $130 billion over the next 10 years.

We need to go much further, clearly, but that reduction is sure a lot better than no reduction. At the same time, our plan would reduce the number of uninsured by 31 million. It would reduce the number of Americans who are uninsured and, at the same time, we will cut the Federal budget deficit. So we are doing both.

This bill reins in costs through changes in spending, reforms how providers deliver health care, and it changes the tax treatment of health care. Savings from this bill are estimated to total $106 billion in 2019. The CBO, Congressional Budget Office, which we all rely upon, expects that, in combination, it would increase 10 to 15 percent in the next decade; that is, savings growth, creative savings would grow by that much. That is what CBO says. That is a strong rate of savings. Those are all provisions to control the excessive growth in health care spending.

Our plan also reevaluates the tax treatment of health care. The current Tax Code includes numerous health care subsidies and incentives. The current tax treatment of certain health care expenses encourages people to spend more on health care than they need to. Why? Because there is no limit under the law, none; that is, all employer- provided health care benefits in America today are totally tax free. The more the benefits are, if a company wanted to provide not only a Cadillac policy but diamond and gold benefits--great benefits--it is not needed tax free. That tends to encourage excessive health care spending. These indirect health care costs totalled nearly $200 billion in 2008. That makes health care the largest Federal tax expenditure. Health care today is the largest Federal tax expenditure. Our laws changed about 60 years ago and moved in that direction, limiting subsidies for expensive insurance plans. Our bill limits incentives to overspend on health care. Our bill will help to slow the growth of health care spending.

Also, the CBO, in a letter they sent to the Congress yesterday, concluded there is about--this provision, the tax on so-called Cadillac plans, would result in a reduction in premiums those persons would otherwise pay--a reduction of, I think, about 5 to 7 percent. There has been a lot of concern in this body and beyond this body that that provision--the Cadillac plan provision--would raise costs for those folks who have those plans. The CBO concluded that the premiums for those kinds of plans would be reduced, I think, by 5 to 7 percent, rather than compared with current law. Several parts of our plan have the effect of reducing costs. I mentioned excess tax on high-cost insurance premiums, and that is a powerful one.

Our plan also caps flexible health savings accounts. It puts a cap on them so it is not unlimited. There is no cap, so the Tax Code tends to encourage excessive use of that provision.

Our plan would also conform with the definition of qualified medical expenses, the definition used by the itemized deduction for medical expenses. That, too, will help.

Reducing existing tax expenditures for health care costs is one of the best ways to slow the growth of health care spending. We could use our code, all the tools available. Our goal is not only to reduce costs but also improve quality. There are many provisions in the bill that accomplish that result, which would improve the quality of health care. A lot of people hear us talk about how costly health care in America is today. It is costly--too costly. There is a lot of waste. We are enacting provisions to cut out the waste.

I sense some Americans are thinking: Gee, maybe they are going to cut my Medicare benefits and reduce the quality back there in Washington, where they are worried about excessive health care costs. The exact opposite is the case. All the provisions in here enhance the quality of health care. The list is very long. One that immediately comes to mind is additional spending for primary care doctors. We all know they are underpaid in America. They are not taking Medicare patients, and they are going out of practice, especially in rural areas. This legislation adds 10 percent additional payment to primary care doctors in each of the next 5 years. That will help primary care doctors continue to practice.

I might mention that health information technology will also help improve quality. There are lots of demonstration projects and pilot projects to improve quality through bundling, care organizations, reining in excessive readmission rates some hospitals have. We also have an outfit that compares how drugs work compared with other procedures. All that is going to help address quality.

I want folks to know that while we are reducing costs--that is true because costs have to be reduced--we are also increasing the quality of health care in America. There are many other incentives in this bill that I don't have time to mention tonight that accomplish that result.

In response to the excise tax on high-cost insurance, insurance companies will offer lower cost plans that fall under the thresholds. I think that is one of the reasons why premiums for those folks will fall. This will give consumers a lower cost alternative. These plans will still have the minimum level of benefits that will be required by law under the health care system.

Other changes to the tax treatment of health expenses will also help individuals make more cost-effective health care decisions. For example, our plan would require employers to tell their employees the value of their health insurance.

That reminds me two of the other provisions for increasing transparency so hospitals tell people what they charge for various procedures. I think the same should also apply to physicians so people have a better idea what they will pay or their insurance company will pay for these procedures.

As I said, our plan will require employers to tell their employees the value of their health insurance. This will help people to know how much they are actually spending.

I mentioned changes to flexible savings accounts, health savings accounts, and the definition of ``medical expenses.'' That will all help. It will also help to reduce costs by increasing competition. That has not been mentioned enough on the floor. This bill increases competition. We all know that in too many of our States, there are too few health insurance companies. In my State of Montana, Blue Cross/Blue Shield provides at least half the market. There is another company that is basically the rest. In some States, Blue Cross has the entire market. It is wrong. There is not enough competition. The exchange we are putting in place will encourage competition.

Do you know what else will encourage competition? That is all the insurance market reforms--all of them--telling companies they cannot deny coverage based on a preexisting condition, telling companies they cannot rate according to health status, dealing with rules in the States, which means when you go to buy insurances--especially as an individual--there will be competition based on price. Companies will basically offer many of the same products, but they cannot deny coverage for preexisting conditions. The effect of that will be prices should come down because there will be more competition when insurance companies base it on price.

Then there is the public option. That is another addition. That is in this bill. We don't know if it will or not. There are a lot of ways we help provide competition. It will help more competition, and transparency will help more competition. Competition is going to help bring down the costs.

Our bill will reduce costs also by reforming health care delivery system--I mentioned a lot of that already--including how we pay for doctors.

The bill is balanced. It finds savings in health care outlays-- savings that are realistic, that make sense. It looks to reduce health tax expenditures. That is a fancy term for deductions. The bill reduces the Federal deficit in the first 10 years. That point needs to be driven home. This bill reduces the Federal deficit in the first 10 years and the subsequent 10 years will have a positive effect bringing down the budget deficit. In fact, CBO says the second 10 years of our plan will cut the deficit by a quarter of a percent of the gross domestic product. That is about $450 billion. That is nearly $\1/2\ trillion in deficit reduction.

We need to remember the cost of doing nothing is unacceptable. Basically, we have two choices in life: try

or do nothing. To ask the question is to answer it. Of course, we tried. Our Nation is in crisis. We have a health care crisis. It is a formidable task. It is exceedingly complex and difficult. But we have an obligation to try, at least try, to fix it.

If we try, then that poses a second question. If we try, we ask the question: Do we try our best or not? The answer is obvious: We try our best.

This legislation is a combination of a year or two of work by folks in the medical profession, of health care economists--Americans who are trying to find ways to get control of costs and improve quality. There are not a lot of new ideas here. They are ideas that have been percolating around for the last year or two. Some are in Massachusetts, some in other States. Some of it is going into integrated systems, such as Geisinger and Intermountain. The idea of bundling is already practiced by other institutions. There is not a lot that is terribly new.

We are pulling together, we are helping establish a policy in our country that comes up with a plan, a system in America that allows doctors and patients to have total free choice. They choose. We are helping doctors with the best evidence, the best information so they can focus on the patient care even more than they are now. We are cutting down the budget deficits. That is very important. And we are also helping Medicare by extending the solvency of Medicare another 5 years. These are things we pulled together and have to do.

I very much hope we can move on and get this legislation passed and work with the House and the President signs a bill that we can start finally putting together something of which we will be very proud. Our country does not have a health care system today. It is a free-for-all. It is a free-for-all for all kinds of groups. This is the first effort to get something together that works, giving doctors and hospitals and patients the choice they want to have and they should have. We are also bringing costs down and improving quality of health care.

Mr. President, I believe Senator Durbin may be coming to the floor. In the meantime, I suggest the absence of a quorum.

Mr. President, before I give a statement on the bill, I wish to compliment the Senator from Maryland for standing up for and essentially helping the health care of women. As she has pointed out, women are discriminated against today in America in various ways. Her amendment addresses some of that discrimination. I very much appreciate that. I know all women in the country do. I do, too. I have a mom. I have sisters. I have women in my family, and I very much care.

I don't know if she made this point, but about 80 percent of health care decisions made for families are made by women. It is all the more important women are not discriminated against, partly because they make so many decisions that affect health care for Americans, but second, women themselves are often discriminated against. Some States have gender ratings which discriminate against women. In other States a preexisting condition is a factor that discriminates against women.

I thank the Senator from Maryland. She has hit the nail on the head. It is another reason this health care reform is going to mean so much for so many Americans. I personally very much thank the Senator from Maryland.

In the Presidential campaign of 1912, Theodore Roosevelt's platform said:

We pledge ourselves to work unceasingly in State and Nation

for . . . the protection of home life against the hazards of

sickness . . . through the adoption of a system of social

insurance adapted to American use.

Today, nearly a century later, we are closer than ever to enacting meaningful health care reform.

As in Teddy Roosevelt's time, we seek protection against the hazards of sickness. Of necessity we seek a system uniquely adapted to American use. And recognizing the daunting task still ahead of us, we pledge ourselves to work unceasingly to get the job done.

In the years since Teddy Roosevelt, some of our Nation's greatest leaders signed up for this job. But at the same time, we have never faced a greater need to get the job done than we do today.

Why is that? Basically because health care costs are skyrocketing out of control. Every day American businesses are forced to cut benefits for their workers. Why? To remain competitive in the global marketplace. Every 30 seconds another American files for medical bankruptcy. Just think of that. Every 30 seconds another American files for medical bankruptcy. Every year, about 1.5 million families lose their homes because of health care costs. Our system is in crisis.

We have a historic need and we have a historic opportunity. We have an opportunity to enact groundbreaking reform that will finally rein in the growth of health care costs and help bring financial stability back to American families and businesses.

Unfortunately, there are some who stand in the way. Unfortunately, there are some who are spreading misinformation about how health care reform will work. On this very floor I have heard arguments that health care reform is about the government trying to take over health care. That is false.

The truth is, health care reform is about allowing patients and doctors to take back control of health care. We need to allow patients and their doctors together to take back control from the big insurance companies.

Our plan would not increase the government's commitment to health care. But don't just take my word for it. The nonpartisan Congressional Budget Office says:

[D]uring the decade following the 10-year budget window,

the increases and decreases in the federal budgetary

commitment to health care stemming from this legislation

would roughly balance out, so that there would be no

significant change in that commitment.

That is right, health care reform will not increase the Federal Government's budgetary commitment to health care.

I have also heard it argued that health care reform will increase the budget deficit. That, too, is false--plainly, patently false.

The bipartisan Congressional Budget Office says our plan would reduce the Federal deficit by $130 billion within the first 10 years--reduce the deficit in the first 10 years. That trend would continue, the CBO says, over the next decade. During the next decade, CBO says our bill would reduce the deficit roughly $450 billion. That is nearly one-half trillion dollars in deficit reduction, according to the Congressional Budget Office, in the second 10 years.

I have also heard it argued that health care reform will raise taxes. That, too, is false. In fact, health care reform will provide billions of dollars in tax relief to help American families and small businesses afford quality health insurance--tax cuts.

The Joint Tax Committee--again bipartisan and which serves both the House and the Senate--tells us, for example, that our bill would provide $40 billion in the tax cuts in the year 2017 alone--$40 billion in tax cuts in the year 2017. The average affected taxpayer will get a tax cut of nearly $450. The average affected taxpayer with an income under $75,000 in 2017 will get a tax cut of more than $1,300.

Let me repeat that. The average affected taxpayer with income under $75,000 in 2017 will get a tax cut of more than $1,300. They will also get a tax cut in earlier years, but it ramps up to that amount in 2017.

In the same vein, I have heard claims that health care reform will result in an increase in higher costs for Americans. That, too, is false.

Health care reform will not result in higher costs for Americans. Health care reform is fundamentally about lowering health care costs and making quality health care affordable for all Americans. Lowering costs is what health care reform is designed to do, lowering costs; and it will achieve this objective. How? In many ways.

First, health care reform will end abusive practices by insurance companies. Reform will stop insurance companies from denying coverage or hiking up rates for those with a preexisting condition. We stop that in this legislation. That will lower costs. Reform will stop insurance companies from dropping coverage or reducing benefits for those who get sick.

Those reforms protect consumers, and they will protect Americans and reduce premium costs for Americans who are sick. These reforms will also help lower costs for small businesses and their employees. Right now, if one employee in a small business gets sick--just one--insurance companies can double the premiums they charge the whole business. I know that is true. I have heard that time and time again from small business owners in Montana. That is just because one employee gets sick, the insurance companies jack up premiums, double the premiums they otherwise would charge the whole business. That is just wrong. We stop that in this legislation.

How else do we lower costs in this bill? Health care reform will provide billions of dollars in tax credits and reform will limit out- of-pocket costs such as copayments that insurance companies are able to charge. We limit them. This will also help to ensure Americans can afford their total health care costs and not just their premiums.

That is very important. Premiums and out-of-pocket costs are both addressed by this bill. It limits growth in premiums and also limits growth in out-of-pocket costs. So total cost--premiums plus out-of- pocket costs--for Americans will be lower under this legislation than otherwise would be.

Third, health care reform will work to repeal the hidden tax of more than $1,000 in increased premiums that American families pay each year in order to cover the cost of caring for the uninsured.

Today, millions of Americans without health insurance are too often forced to turn to emergency rooms to get the care they need, and then health care providers shift the cost of that care to other Americans with health insurance. People with insurance, therefore, pay higher premiums. By providing quality, affordable health insurance to millions more Americans, health care reform will reduce this hidden tax and reduce premiums for all Americans--$1,000 per year per family due to uncompensated care. That is that hidden tax. This bill will virtually stop that hidden tax, stop that additional $1,000 that goes to average family premiums.

How else do we reduce health care costs? By providing affordable health care to more Americans which will increase the number of Americans in the insurance market. Why? What is so good about that?

One reason is more people will have health insurance. But also it will spread the risk of paying for an accident or disease more broadly. Spreading the risk more broadly should lower premium rates for everybody. It is a basic tenet of insurance.

Fifth, health care reform will reduce costs by cutting administrative redtape. That is no small item. Today, insurance companies spend a lot of time and money finding ways to discriminate against people. They spend time and money to find ways to drop coverage, and insurance companies pass those administrative costs on to all Americans in the form of higher premiums. The figure I heard is about 18 percent of American health care dollars is administrative costs. This legislation would dramatically reduce that percentage to a much lower number. We don't know to exactly what level yet but a much lower level. About 18 percent of total health care dollars go to pay administrative costs. That is not the case in other countries. They pay 4 to 5 percent in other countries. We have to get that down in America, and health care reform will significantly achieve that result.

Health care reform will outlaw this discrimination, and also reform will eliminate those administrative costs that go along with it. Furthermore, health care costs will work to streamline administrative procedures across the board by requiring standard enrollment forms and marketing material through insurance exchanges. That, too, will help streamline procedures. That, too, will help reduce administrative costs for providing for standard enrollment forms and also standard marketing materials through insurance exchanges. That is going to lower administrative costs and make it much easier for a person to shop and know which policy is best for him or her. With the other reforms we are making competition is more on the basis of price not just underwriting, a fancy term for denying because of a preexisting condition and putting in all those extra escape clauses insurance companies often provide in small print. In a letter released today, the Congressional Budget Office said:

Compared with plans that would be available in the nongroup

market--

And they are referring there to the individual market--

under current law, nongroup policies under the proposal would

have lower administrative costs.

Let me say that again. Compared with plans that would be available in individual markets--individuals seeking insurance--under current law, individual policies under the proposal would have lower administrative costs.

Lower, not higher. Lower.

Six--another way to reduce costs. Health care reform creates insurance exchanges where consumers can easily shop and compare plans to find the right coverage. Exchanges will make it easier for Americans to choose the most efficient plans, and that will reduce their costs and put pressure on insurance companies to offer lower cost, higher quality plans.

Seven--still another way this bill reduces costs. Small business insurance exchanges will allow small companies to pool together to spread their risk and increase their buying power. More pooling available for small business insurance exchanges--this will allow small businesses to negotiate lower rates and provide more quality insurance plans with lower premiums to their employees.

Eight. Health care reform will strengthen oversight and enforcement measures to cut down on fraud, waste, and abuse in the health care system. Fraud, waste, and abuse are estimated to cost our health care system more than $60 billion every year. This bill will help reform our system to reduce fraud, waste, and abuse, which eats up way too many health care dollars.

Nine. Health care reform will move the focus of our system toward efficiency and value with payment incentives that reward quality care-- not quantity and volume but reward quality care, reward outcomes. Over the long run, paying doctors and other health care providers for quality instead of quantity will reduce health care costs.

Ten. Health care reform will lower costs by working to change the focus of our health care system from treating sickness to promoting wellness. The big problem we have today is that we treat sickness. We don't spend enough time promoting wellness. Reform will make critical investments in policies that promote healthy living and help prevent costly chronic conditions that drive up costs throughout the system.

These are just 10 examples of how health care reform will reduce health care costs and lower premiums for American consumers. There are many more, but these are those 10, as I said. On the other hand, without reform; that is, without passing this legislation, costs are guaranteed to continue to skyrocket out of control.

Since Congress failed to enact health care reform in the 1990s, health care premiums have risen eight times faster than wages. Consider that. Since the last time we attempted to pass health care reform--and failed--in the 1990s, health care premiums have risen eight times faster than wages. And if we don't reform our health care system now, premiums will increase 84 percent in the next 7 years. And that is just premiums. What about out-of-pocket costs? Those, too, will increase at a rate much faster than wage increases.

Today, health care coverage costs the average American family more than $13,000 a year, according to the Kaiser Family Foundation. If current trends continue without reform, the average family plan will cost more than $30,000 a year in the next 10 years. That is up from $13,000 today to $30,000 10 years from now. And businesses could see their health care costs double in that same time. Without reform, our Nation's long-term fiscal picture is almost certainly unsustainable.

As Peter Orszag said when he was Director of the Congressional Budget Office:

Rising health care costs represent the single most

important factor influencing the Federal Government's long-

term fiscal balance.

He was right. Without reform, instead of working to reduce our national deficit and stabilize the Federal budget, we will see total health care spending nearly double to encompass one-fifth of our gross domestic product in less than 10 years. And the Congressional Budget Office projects entitlement spending will double by the year 2050.

Without reform, millions of uninsured Americans will continue to suffer. A Harvard study found that every year in America, lack of health care coverage leads to about 45,000 deaths. People without health insurance have a 40-percent higher risk of death than those with private health insurance. You have a 40-percent higher chance of death if you don't have health insurance compared with those who do. That is 46 million Americans at risk today because they do not have health insurance. A recent Johns Hopkins study found that children without insurance have a 60-percent higher risk of death than those with private health insurance--a 60-percent higher risk of death than those with private health insurance.

Another recent Harvard study found that the risk of dying from car accidents and other traumatic injuries is 80 percent higher for those without insurance--80 percent higher. The risk of dying from car accidents and other traumatic injuries is 80 percent higher if you don't have health insurance. In the greatest country on Earth, no American should die simply because they do not have health insurance.

So, Mr. President, we are at a crossroads in history. We have a historic opportunity to enact meaningful health care reform that will work to stabilize our economy and provide quality, affordable health care coverage for millions of Americans. We are not the first to be here, but we have come further than ever before.

We laid the groundwork in the Finance Committee and the HELP Committee. We held many hearings and countless hours of meetings on health care reform. Each committee crafted meaningful legislation and held exhaustive markups where we incorporated amendments from both sides of the aisle. We produced balanced, meaningful legislation, and I am proud--I am very proud--of the work both committees accomplished. Now we have one health care plan before us in the Senate, two basic bills merged together. We have an opportunity to debate that plan and offer amendments to make it even better. Then we will be called upon to vote.

The health care of our Nation is depending on us. The health care of our economy is depending on us. History itself is depending on us to answer the call. I am confident we will. I am confident we will at long last answer the call of history. I am confident we will soon enact meaningful health care reform that will lower costs and bring quality, affordable coverage to millions of Americans.

Madam President, I have a few small matters here before I yield to my friend from Iowa.

First, I cannot thank my colleague from Connecticut enough. He has worked so hard as the former chairman of the HELP Committee and now as a very active participant in the HELP Committee, along with Chairman Harkin. I cannot thank him enough. The Senator from Connecticut has worked on health care in such a constructive way. I deeply appreciate his efforts.

Before I give up the floor, I wish to pay my strongest compliments to my colleague from Iowa, Senator Grassley. Senator Grassley is one heck of a guy. He represents his State, in my judgment, very, very well. As I am sure the Presiding Officer knows--certainly my colleague from Connecticut knows--we have worked very closely together, Senator Grassley and I, on a nonpartisan basis as much as we possibly can because we both think--and I know most people think--good legislation is legislation where you work together, not where you are fighting each other.

Senator Grassley and I started out trying to get this bill put together on a bipartisan basis working together. As it turned out, we did not quite get there. But I know in the end he would very much like to find a way to vote for health care reform, as most Members of the Senate would.

I am an optimist. I think most of us in this body are optimists. I have not given up yet. Who knows how this is going to evolve? Who knows what the amendments are going to be? Who knows what the votes are going to be in the next several weeks or so? But I am looking for an opportunity where Senator Grassley and other very constructive Senators will join us, all together, in a way, with a little give and take here, perhaps, to find a solution.

So I just want to end by saying how much I appreciate the Senator. He does a super job.

Mr. President, I ask unanimous consent that Stic Harris, a fellow in the office of Senator Franken, be granted floor privileges for the duration of the debate on H.R. 3590.

Mr. President, a noted psychologist once said:

To be mature means to face, and not evade, [a] crisis. . .

.

Our health care system is in a crisis. This crisis has been decades in the making, and history has made clear that this crisis will not solve itself. It is time for us to face the crisis. It is time for Congress to show mature leadership. It is time for us to reform health care, once and for all.

For years now, we have prepared for this moment. The Finance Committee and the HELP Committee studied the issues thoroughly. We have held nearly 70 hearings, roundtables, and walk-throughs. We have studied this issue very thoroughly and exhaustively. We each produced a blueprint for reform--each committee--and we worked together with Leader Reid and President Obama to combine those blueprints into one solid plan. This week, tonight, we have brought that plan to the Senate floor. Tonight, we seek to begin that momentous debate. Tonight, we seek, at last, to face the crisis.

We have a bill that will put Americans, patients, and their doctors back in control. We have a bill that will end harmful insurance industry practices. Under our bill, no longer will insurance companies be allowed to deny you health insurance. No longer will insurance companies be allowed to hike up rates for Americans with preexisting conditions, such as heart disease, cancer, or diabetes. No longer will health insurance companies be able to take away your health insurance or reduce benefits when people get sick. Under our bill, no longer will insurance companies be able to limit the amount of health care you can use in a lifetime. No longer will insurance companies be able to put unreasonable limits on the amount of health care you can use in 1 year. If you pay your bill, the insurance company must renew your coverage and provide your benefits. No longer will insurance companies be able to discriminate based on gender or health status. No longer will insurance companies be able to charge more for women or for people who are sick.

Our bill will also require insurance companies to disclose the share of premiums that goes to medical benefits. That is new and very important. No longer will insurance companies receive tax credits when they use their profits to provide excessive executive paychecks.

Our bill is fully paid for. It is fiscally responsible. It will lower health care costs, and it will reduce the Federal budget deficit.

According to the Congressional Budget Office, our bill will reduce the deficit by $130 billion in the first 10 years. Over the next decade, it will further reduce the deficit by about one-quarter of 1 percent of gross domestic product. That is hundreds of billions of dollars in deficit reduction.

As well, our bill will provide billions in tax cuts for American families and small businesses. Our bill will create new marketplaces called insurance exchanges. Individuals and small businesses will be able, quickly and easily, to view, compare, and buy health insurance plans.

Today, many Americans already receive quality health care coverage through their employers. Many are happy with their current insurance plans. This bill will not change that. We keep the best of our current health care system. People who are satisfied with their current health insurance coverage will be able to keep it. But too many others do not have access to insurance, to quality insurance. For too many, this system is broken.

Under our bill, new exchanges will provide one-stop shops where plans are presented in a simple, consistent format. Americans will be able to know exactly what they are buying. Insurance companies will have to compete on price and on quality, not on their ability to select the healthiest people or hide restrictions. Americans will be able to count on the health care coverage they buy. And tax credits will help to ensure all Americans can afford quality health insurance.

Small businesses will also have access to exchanges and tax credits. Through small business exchanges, these companies will be able to pool together to spread their risk, increase their leverage, and enhance their choice, just as big companies do.

Members of Congress will be required to buy their health insurance through the same exchanges that people in their own States use--exactly the same. No longer will there be a separate congressional health plan.

Our bill will strengthen Medicare. It will improve benefits for seniors. And it will help to ensure Medicare is sustainable for future generations. Our bill will cut costs, but it will not cut benefits. Our bill will increase Medicare benefits. Our bill will provide seniors with free preventive care and wellness checkups. It will improve care for seniors with chronic conditions. And it will provide a 50-percent discount on brand-name prescription drugs to help close the doughnut hole, the gap in benefits in the Medicare prescription drug program.

Our plan is a good, commonsense answer to the crisis facing American families and businesses.

On this floor, here in the Senate, tonight, we have a historic opportunity to consider this plan. We have the chance to make it even better. We hope to have a full debate. But more important than the process or rhetoric, we have the opportunity, at last, to face the crisis. We have the opportunity to show mature leadership. At long last, we have the opportunity, the historic opportunity, to reform health care, once and for all. History is knocking on the door. Let's open it. Let's begin the debate to improve this bill before us today and provide the service all Americans expect us to perform when they elect us to this office.

I yield the floor.

Mr. President, I ask unanimous consent that Jacqueline Lampert, a Democratic Policy Committee staffer, be granted floor privileges for the consideration of H.R. 3590.

Mr. President, due to an unfortunate illness in my family, I regrettably missed rollcall No. 352. If I had been present, I would have voted ``aye'' on the passage of S. 1963, the Caregivers and Veterans Omnibus Health Service Act of 2009. This legislation is very important to veterans living in Montana. Many of Montana's veterans live in rural areas, hours away from the closest VA facility, and this bill will improve access to health care in those rural areas. I am pleased to see this bill passed with bipartisan support. We must uphold our promise to honor our veterans and provide them with the benefits they have proudly fought for and deserve.

Today, I am pleased to introduce the Small Business Penalty Relief Act of 2009 with my good friend and Ranking Member of the Finance Committee, Chuck Grassley.

The bill provides much needed penalty relief to small businesses across America that are being assessed large penalties by the Internal Revenue Service because they unknowingly invested in something called a ``listed tax shelter transaction.''

Many of these businesses thought they were putting their money into sound investments for the benefit of their employees and learned only after they were audited by the IRS that they instead had invested in something the IRS considers to be a tax shelter.

Most small businesses do not have the resources to pay sophisticated tax lawyers and accountants to review all their business decisions. They have to do the best they can on their own. And that is how they ended up in the middle of a nightmare with the IRS.

When a business invests in a listed tax shelter, the law requires that business to attach a form to the tax return telling the IRS about the shelter. If the business doesn't attach the form, it can be subject to a penalty of $200,000 per year. If the business has elected Subchapter S status, an additional $100,000 penalty applies at the individual level. Total penalties can add up to $300,000 each year. Multiply that by several years, and you can easily approach $1 million or more in penalties for a tax shelter you didn't even know you had.

In the case of many small businesses, the annual tax benefit from their investment is quite minor--perhaps as small as $15,000. The $300,000 penalty plainly is out of whack.

Just to be clear, Senator Grassley and I are not soft on tax shelters. We spearheaded legislation in 2004 that gave the IRS better tools to stop individuals and big companies from cleverly manipulating the tax code to avoid paying the taxes they owed. Our efforts were focused on egregious deals that cheated the U.S. Government out of millions and billions of dollars. Our efforts have made a serious dent in the proliferation of abusive tax scams and schemes.

But we didn't intend that the 2004 legislation would end up threatening the existence of small businesses in Montana and across America, and the livelihoods of their employees who risk losing their jobs if the business goes under.

Small businesses are struggling already. They don't need the added and unfair burden of a penalty that can be as much as 20 times larger than the taxes they saved.

This bill changes the way the penalty is calculated. The penalty is based on a percentage of the tax benefit resulting from the investment. It is fairer and won't drive these companies out of business.

Small businesses are the backbone of our Nation. Particularly in these tough economic times, we must make sure the tax laws reflect the important role that small business plays in our Nation's economic health and our citizens' economic security.

Today, I am pleased to introduce the Small Business Penalty Relief Act of 2009 with my good friend and Ranking Member of the Finance Committee, Chuck Grassley.

The bill provides much needed penalty relief to small businesses across America that are being assessed large penalties by the Internal Revenue Service because they unknowingly invested in something called a ``listed tax shelter transaction.''

Many of these businesses thought they were putting their money into sound investments for the benefit of their employees and learned only after they were audited by the IRS that they instead had invested in something the IRS considers to be a tax shelter.

Most small businesses do not have the resources to pay sophisticated tax lawyers and accountants to review all their business decisions. They have to do the best they can on their own. And that is how they ended up in the middle of a nightmare with the IRS.

When a business invests in a listed tax shelter, the law requires that business to attach a form to the tax return telling the IRS about the shelter. If the business doesn't attach the form, it can be subject to a penalty of $200,000 per year. If the business has elected Subchapter S status, an additional $100,000 penalty applies at the individual level. Total penalties can add up to $300,000 each year. Multiply that by several years, and you can easily approach $1 million or more in penalties for a tax shelter you didn't even know you had.

In the case of many small businesses, the annual tax benefit from their investment is quite minor--perhaps as small as $15,000. The $300,000 penalty plainly is out of whack.

Just to be clear, Senator Grassley and I are not soft on tax shelters. We spearheaded legislation in 2004 that gave the IRS better tools to stop individuals and big companies from cleverly manipulating the tax code to avoid paying the taxes they owed. Our efforts were focused on egregious deals that cheated the U.S. Government out of millions and billions of dollars. Our efforts have made a serious dent in the proliferation of abusive tax scams and schemes.

But we didn't intend that the 2004 legislation would end up threatening the existence of small businesses in Montana and across America, and the livelihoods of their employees who risk losing their jobs if the business goes under.

Small businesses are struggling already. They don't need the added and unfair burden of a penalty that can be as much as 20 times larger than the taxes they saved.

This bill changes the way the penalty is calculated. The penalty is based on a percentage of the tax benefit resulting from the investment. It is fairer and won't drive these companies out of business.

Small businesses are the backbone of our Nation. Particularly in these tough economic times, we must make sure the tax laws reflect the important role that small business plays in our Nation's economic health and our citizens' economic security.

Mr. President, I rise today to honor and pay tribute to Montana's fallen heroes, the dedicated men and women from our great State who have made the ultimate sacrifice in Iraq and Afghanistan since 9/11.

Montanans proudly volunteer for military service at rates higher than any State in the country, higher per capita. Unfortunately, this distinction comes at a great price. To date, 40 Montanans have died and nearly 250 have been wounded in combat in Iraq and Afghanistan. Montana has now suffered more casualties per capita than any other State in the Union. This is staggering. It illuminates just how much our State's citizens have sacrificed in the service of our country.

The famous World War II radio reporter Elmer Davis once said:

This Nation will remain the land of the free only so long

as it is the home of the brave.

It is painfully apparent that Montana is home to some of the bravest men and women of all. Who are these fallen heroes? They range in age from 18 to 40. They hailed from places far afield, such as Troy and Glendive, Billings and Missoula, Lame Deer and Colstrip. They grew up in cities and towns, on ranches and farms, and on the reservation. Some heroes were Active-Duty warriors, others part-time citizen soldiers. They held ranks from lance corporal to lieutenant colonel. It amazes me that with such a variety of backgrounds, our heroes all shared the common bond of a desire to serve their country in this time of crisis and need.

The Gospel of John, chapter 15, reads:

Greater love hath no man than this: that a man lay down his

life for his friends.

No tribute could possibly express the extent of my gratitude for what these soldiers, sailors, airmen, and marines have done for their country.

During Vietnam, the late Senator Mike Mansfield carried a casualty card in his breast pocket. In that same spirit, I, too, wish to honor their sacrifice by reading Montana's fallen heroes into the Record. The following Montanans were killed while serving in Operation Iraqi Freedom:

Army SGT Travis M. Arndt, 23, Bozeman; Army SSG Travis

Atkins, 31, Bozeman; my nephew, Marine Cpl Phillip E. Baucus,

28, Wolf Creek; Army SSG Shane Becker, 35, Helena; Marine PFC

Andrew D. Bedard, 19, Missoula; Marine LCpl Nicholas William

Bloem, age 20, Belgrade; Army PFC Kyle Bohrnsen, 22,

Philipsburg; Army LTC Garnet Derby, 44, Missoula; Army SGT

Scott Dykman, 27, Helena; Army SPC Michael Frank, 36, Great

Falls; Marine LCpl Kane Michael Funk, age 20, Kalispell; Army

SSG Yance T. Gray, 26, from Ismay; Army SSG Aaron Holleyman,

26, Glasgow; Army PVT Timothy J. Hutton, 21, Dillon; Navy PO2

Charles Komppa, 35, Belgrade; Army CPL Troy Linden, age 22,

Billings; Army CPT Michael McKinnon, 30, Helena; Army SGT

James A. McHale, 31, Fairfield; Army MSG Robbie McNary, 42,

Lewistown; Marine LCpl Jeremy Scott Sandvick Monroe, 20,

Chinook; Army PFC Shawn Murphy, 24, Butte; Marine LCpl Nick

J. Palmer, 19, Great Falls; Army CPT Andrew R. Pearson, 32,

Billings; Marine Cpl Dean Pratt, 22, Stevensville; Army SPC

James Daniel Riekena, 22, Missoula; Army 1LT Edward M. Saltz,

27, Bigfork; Army PVT Daren Smith, 19, Helena; Marine Cpl

Raleigh C. Smith, 21, Troy; Marine Cpl Stewart S. Trejo, 25,

Whitefish; Army PFC Owen D. Witt, 20, Sand Springs; Army SPC

Donald M. Young, 19, Helena; Army PVT Matthew T. Zeimer, 18,

Glendive.

The following Montanans were killed while serving in Operation Enduring Freedom:

Navy aviation electronics technician, Andrew S.

Charpentier, 21, Great Falls; Army 1LT Joshua Hyland, 31,

Missoula; Marine Sgt Trevor Johnson, 23, Colstrip; Army SGT

Terry Lynch, 22, Shepherd; Army PFC Kristofer T.

Stonesifer, 28, Missoula.

The following Montanans died shortly after returning home from Operation Iraqi Freedom: Army CPL Christopher M. Dana, 23, Helena; and Army SGT George Kellum, 23, Lame Deer.

It pains me dearly to read this list out loud and I cannot begin to imagine how many broken hearts each name represents back home. Our fallen heroes fought and died for our great Nation and all it represents. We owe them a debt of gratitude that can never be fully repaid. We must honor their legacies by remembering their sacrifice as we carry on with our lives.

To all of Montana's families staring at an empty bedroom or an empty chair at the dining room table: You will always be in my thoughts and prayers. I pledge to do all I can to honor your fallen loved ones.

To Montana's fallen warriors: We will never forget.

I yield the floor.

I suggest the absence of a quorum.