Floor Statements

That is absolutely the case. I would like to point out, when we had the Finance Committee markup, I asked CBO Director Elmendorf directly whether provisions in the bill,

which are still in the bill, would reduce the benefits that Medicare recipients received. His response was:

For those who would be enrolled otherwise under current

law, yes.

There has been a lot of talk here about we are not cutting Medicare benefits or we are or it is this or that. The bottom line is, the CBO Director said it: Yes, we are cutting benefits.

I would like to ask the sponsor of this motion a question because I know there are some who are saying the reason we are cutting Medicare Advantage is that it is so expensive, and we should be cutting Medicare and controlling its costs; that it is about 14 percent more expensive than fee-for-service Medicare.

Some people say if you are defending Medicare Advantage, you are defending overpayments in health care plans. Would the Senator from Utah like to respond to that criticism some are making?

The Senator is absolutely right. A lot of people trying to defend these cuts are saying these extra costs in the Medicare Advantage Programs are just going to make insurance companies' profits bigger and help pay for large CEO salaries. Nothing could be further from the truth. The reality is, as the Senator from Utah already indicated, 75 percent of this 14 percent extra payment in these plans go to provide the seniors with the extra benefits we are talking about, and then 25 percent is returned to the Federal Government, not to insurance companies, not to CEOs.

I have a chart. We are going to make it into a bigger one. But those who support this program say we are not cutting Medicare benefits. This chart--I apologize it is a little bit small--but this is a chart of the United States. It shows what is happening to the benefits of Medicare Advantage beneficiaries. As you might guess, the dark red is more than 50 percent reduction in the benefits of the people in those dark red States. In the medium red color, it is between a 25- and 50-percent reduction in coverage. The only States that do not have a reduction in coverage are the white ones. There are three or four States that are not seeing deep cuts in Medicare Advantage benefits.

Those who say--like the President who said it was one of his goals-- if you like what you have, you can keep it--not if you live in one of the States that is not in white on this chart because your benefits will be cut.

Yes, I would. This chart shows the last two sentences of our colloquy when we were in the Finance Committee, but it went on for some time. But the bottom line is that I was asking the Director of CBO whether the cuts to Medicare Advantage that are in the bill would reduce benefits to senior citizens, and he said yes. And the reason he used this phrase here, which says ``for those who would be enrolled otherwise under current law,'' the reason he prefaced it that way-- which we don't have on the chart--is that for future seniors it will not be a viable option. So in the future, those who are not on it now won't have a significant viable option to get on it because it is going to be gutted.

So he was saying that for those 75 percent--and by the way, Medicare Advantage is the most popular part of Medicare today. It is the fastest growing part of Medicare. It is popular because it provides these additional benefits that seniors have to pay so significantly for to get in supplemental insurance that AARP is going to provide. So what the CBO Director said was that for the future, those who aren't already on it won't get it.

I wish to make a comment or two and then engage with the ranking member of the Budget Committee.

Often people talk about driving the cost curve down. Frankly, when you talk to Americans about what they want in health care reform, the vast majority of them say the reason we need health care reform is because of the skyrocketing cost of health care and health care insurance. Those who are promoting this bill say they are bending that cost curve down. My question is which cost curve are they talking about? Is it the size of government? Are they bending the size of government growth down? No, as the Senator from New Hampshire said, they are growing government by $2.5 trillion for the first true 10-year period of the bill.

Are they driving personal health care costs down? No, the CBO report we recently got said 30 percent of Americans will see their health insurance go up, and the other 70 percent will, at best, see it stay about what it is today, rising at the same levels it is today.

Are they talking about the Federal deficit? The chairman of the Budget Committee has indicated to us we are going to see skyrocketing deficits. Those who claim this bill is going to reduce the deficit can say so only if they take into account all of their budget gimmicks, such as not counting the first 4 years of the spending, or the hundreds of billions of dollar of taxes that are going to be imposed on the American people, or the Medicare cuts we have been talking about. Take any one of those three out of this bill and it drives the deficit up in a skyrocketing fashion, is that not correct, Senator?

If the Senator from Oklahoma will respond to a question, he is a physician, and he has very well pointed out how the cuts to Medicare Advantage will reduce benefits to senior citizens. The impacts on the hospitals and home health care and the skilled nursing facilities and so forth will be reduced services. I am aware of a June 2008 report from the Medicare Payment Advisory Commission, MedPAC, which said 29 percent of Medicare beneficiaries they surveyed who were looking for a primary care physician had trouble finding one who would treat them. A similar survey in Texas showed that in that State, only

58 percent of the State's doctors would be willing to take a new Medicare patient, and only 38 percent of the primary care doctors accepted new patients.

So my question is, in addition to the reduction of benefits, in addition to the reduction of access to hospitals and skilled nursing facilities and so forth, won't these cuts and the impact on Medicare also represent a lack of ability by Medicare recipients to literally find physician care?

I thank the Senator from Wyoming for that question, because as we have already reviewed, there will be major cuts in benefits to Medicare, to the Medicare Advantage Program. There are going to be major reductions in access to Medicare, in terms of access at hospitals and skilled nursing homes and facilities and home hospice and other care.

But one of the other things we haven't focused on--and it is kind of interesting that today is the big White House jobs summit--what is going to happen as a result of these Medicare cuts. In addition to the reduction of access and care and benefits to seniors, we are going to lose jobs. I have had in my office here representatives of nursing and home health care facilities from Idaho who have told me that if this bill is adopted, a number of those facilities are simply going to have to go out of business or they are going to have to dramatically reduce the services they provide, meaning that the nurses and the other caregivers who work there will no longer have jobs. That is part of the way our senior citizens will lose access because there will simply be fewer places, fewer physicians, fewer facilities that will take Medicare patients with this kind of an attitude of the Federal Government toward funding of Medicare.

In the end, what do we have? We have a massive expansion of government, $2.5 trillion for a massive new entitlement program, along with which come these incredible government controls over the economy, as well as the creation of a new government insurance company, funded by $\1/2\ trillion, almost, of Medicare cuts, $\1/2\ trillion in taxes, and a massive debt, an unfunded mandate pushed on to the States.

That is one of the reasons why I think the Senator from Arizona was so wise in bringing this motion as the first step in focusing on one of the first fixes that needs to be made to this bill. Let's step back. Let's not pay for a brandnew $2.5 trillion entitlement program on the backs of our senior citizens.

According to the Senator from Tennessee, it is my understanding that nationwide it is about one-quarter of all Medicare beneficiaries. About one in four Medicare beneficiaries in America will see their benefits cut. All Medicare beneficiaries will see their access cut. So these problems we are talking about are not just limited in their impact.

Mr. President, I wish to continue discussing the health care legislation we just voted on. We had a series of votes dealing with the Medicare issue. I wish to start my remarks by turning to the Senator from Mississippi, Mr. Wicker, and ask him if he has comments he wishes to make.

Mr. President, I thank the Senator from Mississippi.

Mr. President, I ask unanimous consent that several of my colleagues and I may engage in a colloquy during the time we have.

Thank you, Mr. President.

I wish to follow up on the comments of Senator Wicker from Mississippi because it is very critical that the American public understand what has happened in the Senate.

When you talk about health care reform, the vast majority of Americans have a couple of ideas in mind. First and foremost, they want to lower health care premiums and costs. That is what Americans think about primarily when they think about the need for health care reform.

They also want to see better access to quality health care and make sure those who are uninsured have access to health care, and those who are underinsured have access to health care, and that we all have access to quality health care. That is what this debate should be about.

But, instead, the legislation we see before us does not achieve that. Does it reduce the cost of health care? No. It drives up the cost of health care. It raises taxes hundreds of billions of dollars. It cuts Medicare by hundreds of billions of dollars. It grows government by $2.5 trillion of new spending. It forces the most needy in our society into a failing Medicaid system. It imposes a damaging unfunded mandate on our struggling States. It still leaves millions of Americans uninsured and establishes massive government controls over our health care economy, including the creation now of a government insurance company.

We have been focusing in the debate on one part of this for the last little while; that is, the Medicare cuts. Mr. President, $464 billion of the revenue to pay for this massive new entitlement that is being created is to come from Medicare, and it is nothing other than a direct transfer of assets in the United States from America's seniors in the Medicare system to a new government entitlement program.

There are other cuts. There are details of these cuts that I will put up right now on a chart.

The debate we have been having over the last, oh, almost 3 or 4 days now, is whether we should commit the bill back to the Finance Committee so these Medicare cuts can be removed. We just had two votes. One was what I will call a cover vote. It said we do not want to cut Medicare benefits and we should make sure that anything we do protects Medicare. It did not have any detail in it, but it passed 100 to nothing because it does nothing. It does not change what is in the bill. By the way, as I said, that vote just passed by 100 to nothing.

The second vote we took failed. Was the vote 40 to 60? I do not recall the exact vote. What would that amendment have done? That amendment would have put the bill back into the Finance Committee and required that we take out the Medicare cuts.

So let no one be confused, after the first round now in the Senate, we still see this in the bill--a transfer of $464 billion from the Medicare Program to the establishment of a new entitlement program. I do not believe that is what Americans had in mind when they were talking about reform of health care.

There has been a study that came out--OK. I have the exact vote here. It was not 40 to 60. It was 42 to 58, but it was defeated, in any event, and now we still have the cuts to Medicare in the bill. Well, we are going to continue debating this issue.

I myself have an amendment that will send--for the skilled nursing homes--the bill back to Finance to correct the cuts for the skilled nursing homes. There are others who will try to address some of the pieces of this legislation to see if we can't find a way to fix and restore the strength and stability of the Medicare system.

Everyone admits we need to reform Medicare. But until this bill, none of us thought we were talking about taking from Medicare in order to create a massive new entitlement program, with the government control that comes along with it.

What do these cuts do? I am going to start out with the hospitals, the hospice services, the nursing homes, and the home health agencies. The reduction in Medicare spending on these medical providers will basically result in lower access to care for our seniors. I have had representatives in my office of both skilled nursing facilities and home health agencies who have talked to me about what this means to them. They have pointed out that the last time Congress did something like this, we lost, in Idaho, 30 percent, for example, I believe it is, of our home health agencies. They are not there anymore. If we have these kinds of deep cuts in the future, we are going to lose more of our home health care agencies.

One of the owners said to me--he put it this way: If you reduce the allocation of income to home health agencies, I have to either reduce employment, which means not hire as many nurses and medical providers, or I have to close parts of my building and stop operating as many rooms in the building, or do something to reduce costs.

What that means is that seniors will have less access. But that is not all this bill does. In addition to reducing the access for hospitals, hospice service, nursing homes, and home health agencies, it also cuts Medicare Advantage deeply.

Quickly, what is Medicare Advantage? Medicare Advantage is a program that about one out of four American seniors participate in in Medicare. It is an opportunity which Congress started a few years back to try to let the private sector become a part of the delivery system in Medicare. In other words, to put it simply, private sector insurance companies can contract with the Federal Government to provide Medicare services to Medicare beneficiaries, so it is the private sector getting involved in health care delivery rather than the government simply delivering the health care through a single-payer system. That, in a quick summary, is what Medicare Advantage was all about.

What we found was that it was phenomenally successful because the private sector was able, through its management, to not only provide the statutorily required Medicare coverage but additional benefits, very critical additional benefits, such as preventive health care, dental coverage, vision coverage, and things such as that--things that make a big difference in the lives of our seniors and enables some of those who cannot buy additional coverage for those things Medicare does not cover to get access to it through Medicare Advantage.

That is why in my State 27 percent of all of the Medicare recipients have moved to Medicare Advantage. It is the most popular part of Medicare in America today, and it is growing faster than any other part of Medicare because it is delivering more to the Medicare beneficiaries.

This bill slashes $120 billion from it, some of us believe because there is a bias against the private sector delivery of health care. But for whatever reason, the Medicare Advantage portion is where the cuts are focused.

Let's put up the next chart.

When we had the issue before the Finance Committee, we had the head of CBO before us, and I asked him a question about the cuts to Medicare Advantage. We had a colloquy between us at that point, and I asked:

So, approximately half of this additional benefit--

In other words, these additional things that Medicare Advantage has been able to provide to our seniors under Medicare--

So, approximately half of this additional benefit would be

lost to those current Medicare Advantage policyholders?

And his response was:

For those who would be enrolled otherwise under the current

law, yes.

The point being, not only will we lose skilled nursing facilities, home health care, hospice care, and hospital care, and access to that care, we are also going to see senior citizens lose benefits. Again, what is the purpose? The purpose is not to shore up Medicare. In fact, it will take $464 billion--taxpayer dollars that are allocated to Medicare in our current system--and transfer that straight over to the establishment of a new entitlement program.

I want to let my colleague from Nevada comment on this for a minute, but before I turn it over to my colleague from Nevada, I wish to point out that as we approach this issue, the question of why would we transfer $464 billion out of the Medicare system to a new government entitlement program, one of the reasons is because the President pledged he would not sign a bill that did not reduce the deficit.

As I said earlier, this bill grows the spending in the Federal Government by approximately $2.5 trillion over the first full 10 years of its implementation of spending. The only way to cover that increase in the size of the government is to either raise more taxes or to cut spending somewhere, and what the bill does is both. It raises taxes-- which we are going to be talking about in future days--and it cuts spending. The place where it cuts spending is Medicare. That is why what we see is increased taxes, cuts in Medicare, growth of government, and the establishment of a new Federal entitlement program, with all of the accompanying accoutrements of Federal control, including a new government owned and operated insurance company.

I see my colleague from Nevada standing and turn to him for his comments on this issue.

The Senator from Nevada is correct. In fact, I am just thumbing through here to get the exact statistics. But the bottom line is, the CBO indicated, I think it was something like from an average number of $140 or so of extra benefits--that it would go down to about half of that. So they would get about half of those extra benefits.

Per month.

That is correct.

I would be happy to yield.

The Senator from Nevada is correct. I have in front of me the exact numbers right now from CBO that were provided in the Finance Committee markup. During the markup, CBO estimated that the value of the extra benefits offered by Medicare Advantage plans will drop from $135 a month to $42 a month, based on the cuts contained in that bill, which are essentially the same level of cuts we now see in the bill before us on the floor.

If I could interrupt, my understanding is, the Republican bill in the House, which has both ideas in it and which was evaluated, what it would do to the cost of health care and health care insurance premiums, that those ideas would actually reduce health care premiums by, I think, 5 or 6 or 8 percent. I don't remember the exact number, but the point is, those ideas would hit the reason Americans want health care reform; that is, reduce the cost of health care coverage.

I know my colleague from Mississippi wants to make a comment or two, but may I ask, Mr. President, how much time remains for our side?

Thank you very much. I wish to use the remainder of our time to speak for a minute about what this bill does to different costs in our country. I think the point we made in this colloquy is, after the votes we just took, let no one be confused; the $464 billion of cuts to Medicare remain in the bill.

Let's talk about the question of the cost curve. There has been a lot of talk about what has become known as the cost curve. It has been said by everybody we need to bend the cost curve down. Some are saying this bill bends the cost curve down. Well, which cost curve are they talking about? Are they talking about the size of government, the growth of government? No. If you take the first full 10 years of the growth of spending in this bill--which, by the way, is delayed for 4 years--if you start when the spending starts and take the first full year, 10 years of spending, the new spending, the growth of government is about $2.5 trillion. I don't see how anybody could say that cost curve is bending down. It has skyrocketed.

Well, would it be the cost of health care, which I think is the cost curve Americans were thinking about, health care insurance and the quality of health care that is provided? Well, CBO just came out with its report that analyzed that issue and there are a number of independent groups that have analyzed it and they all pretty much say it is not going to reduce the cost of health insurance. It is not going to reduce the cost of health care. In fact, for

the neediest in America, those who are in the individual market, it will drive up the cost of their insurance and not by just a little bit, by around 10 to 13 percent. For those in the small group area, it will drive up theirs--not as much--by about 1 to 3 percent. For those in the large group area, there is a possibility that theirs might taper off a little bit; the estimate is somewhere between zero impact and 2 percent reduction.

But is that what we are talking about in America, 30 percent of the people in this country seeing their health care insurance costs go up and the rest seeing theirs remain basically stable? That is not the cost curve reduction I thought Americans were talking about in health care reform.

So then what other cost curve could they be talking about? Well, there is a lot of talk about the deficit. Sometimes they try to shift away from the cost of health care to the cost of the bill to the people of America, and they say the deficit is reduced. Well, how can you say that? There is only one way you can say that and that is if you accept the budget gimmicks in the bill. If you raise taxes by around $500 billion and if you cut Medicare by $464 billion, then you can say this massive expansion of government is somehow covered and that the deficit won't grow.

Well, I think we have talked about the Medicare cuts part of this. We are going to talk about the tax increases, which are hundreds of billions of dollars of new taxes in the future, but what did I mean when I said you can only say the deficit goes down if you accept the budget gimmicks?

This bill starts the collection of revenues and the cuts out at the front end but doesn't start the spending for 4 years, so you have 10 years--in the 10-year window we are looking at, we have 10 years of revenue and 6 years, basically, of spending. Sure, if you only count 6 years of the spending side of the bill against 10 years of its collection side, you are going to be able to make that deficit look a little better.

In addition, there are major expenditures we all know are going to have to be done in health care, such as the SGR fix for physician compensation in Medicare, that are not even in the bill, an expense we know over 10 years is around 200 billion to 250 billion of extra dollars; simply not there, not counted. Well, if you want to show a deficit reduction, you certainly want to leave out of your bill a lot of the spending you are going to do in the future. It is gimmicks such as these, it is tax increases, and it is Medicare cuts that allow one to say the deficit goes down.

In conclusion, the reality is, this bill will increase the growth of government by $2.5 trillion for a full 10-year measure, increase taxes by hundreds of billions of dollars, cut Medicare by hundreds of billions of dollars, create a Federal insurance company, create massive Federal controls over the health care economy, push the neediest of the uninsured not into an insurance policy but into a failing Medicare system, and push an unfunded mandate of tens of billions of dollars onto our States. That is not the kind of health care reform we need. As my colleague from Nevada indicated, there are reforms that do make a difference that will reduce the cost of health care, that will cut down the spiraling costs of health care insurance, and will not require us to have such an intrusion of the Federal Government into the management of our economy.

It is time for us to slow down and start, step by step, to address the kinds of reforms that will reduce the cost of insurance and the cost of health care and that will help us to increase access to quality care in America. We can do it, and we have a number of very good ideas on the table we will be exploring in greater detail in future days as well that will help us to do it.

With that, I reserve the balance of our time.

May I ask how much time remains?

I thank the Chair.

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

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

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

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

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

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

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

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

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

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

Mr. President, how much time remains?

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

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

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

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

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

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

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

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

Mr. President, I appreciate the opportunity to be here with my colleagues from Arizona, Mississippi, and Florida.

When the people of the United States talk about health care reform, they are seeking some way to control the punishing and skyrocketing increases, year after year, in health care insurance costs and medical costs and better access and quality of health care. Yet when this 2,074-page bill, which was crafted in secret for the last 2 or 3 weeks, was finally revealed, that is hardly what we got. In fact, the reality is that this bill will drive up the cost of health care insurance and medical care in this country. It will increase taxes by hundreds of billions of dollars. It will cut Medicare by hundreds of billions of dollars. It will grow the Federal Government by $2.4 trillion of new spending over a 10-year period. It will push the needy uninsured not into subsidized health care insurance but into a failing entitlement program, Medicaid. It will impose a damaging unfunded mandate on States that are already strapped financially. It will leave millions of Americans uninsured, while probably creating the most enormous and massive government extension of Federal control over our economy that we have seen in our country, starting with creation of a new federally owned and managed insurance company.

As the Senator from Arizona indicated, today we are here to focus on the Medicare cut aspect of this legislation. The Senate bill contains something in the neighborhood of $500 billion of cuts in Medicare. The first one I want to focus on is the one the Senator from Arizona already identified; that is, the Medicare Advantage cuts.

The Senate bill contains $118 billion in cuts to the Medicare Advantage Program. Let me talk about that program for a minute. Currently, there are nearly 11 million seniors, as has been indicated, enrolled in Medicare Advantage. That represents about one out of four of all Medicare beneficiaries in the United States. In my State of Idaho, there are more than 60,000 Medicare Advantage beneficiaries, which is about 27 percent of the population in Idaho.

In addition, this is an extremely popular program. A 2007 study reported very high overall satisfaction with the Medicare Advantage Program. Eighty-four percent of the Medicare respondents said they were happy with their coverage and 75 percent would recommend Medicare Advantage to their friends or family members. Yet, despite this, there are massive cuts coming forward in the bill. Why would that be the case?

I don't think most Americans who are not on Medicare recognize the difference between Medicare generally and Medicare Advantage. Medicare Advantage was a modification of the traditional Medicare Program that, frankly, was put into place--I ask my colleague from Arizona to comment. Wasn't it put into place when the Republicans were in control of the Congress to try to help get market forces more engaged and involved in the administration of Medicare benefits?

If you look at the Federal entitlement program Medicare, the portion of Medicare that truly does have some private sector involvement, where private sector companies can come in and contract to provide the government's responsibilities under Medicare, it is the most popular of all Medicare programs, the one that was growing and letting the private sector deliver the benefits.

One of the aspects of the Medicare Advantage Program is that senior citizens on Medicare Advantage actually get additional benefits beyond those traditional Medicare benefits that those in the normal or standard Medicare Program get because the private sector options have been able to identify ways to enhance and create opportunities for greater and stronger benefits.

Yet those who don't want to have anything but a single-payer system, those who want to make sure the government-provided health care is provided only by the government, do not like the Medicare Advantage Program. So it is not surprising that we see this level of cuts in this program.

During the Finance Committee markup, CBO estimated that the value of extra benefits that Medicare Advantage plans provide will drop from $135 a month to $42 a month of extra benefits. The CBO Director, Mr. Elmendorf, confirmed this during the markup. I asked him:

So approximately half of the additional benefit would be

lost to those current Medicare Advantage policyholders.

His answer was:

For those who would be enrolled otherwise under current

law, yes.

In other words, compared to current law, if these cuts are put into place, about half of the benefits would be lost to these Medicare Advantage beneficiaries.

We now have more detail on that. I am sorry we don't have a bigger chart. We will have one in the future. If you can see the United States here, the States in the deep red are those that have cuts in excess of 50 percent to their Medicare Advantage beneficiaries; those in the lighter red are between 25 and 50 percent. In the white, there are only five States; they are the ones that don't have a negative impact. So 45 of the 50 States will see significant reductions in the Medicare Advantage benefits that are provided to their constituencies. You just have to look at the map to see it is a large percentage of those 45 States that are getting cuts in excess of 50 percent of their benefits.

Yes.

The Senator is right. The way I look at it is that it is the extras. Some say Medicare benefits aren't being cut by these proposals, but that is a real stretch. When you look at Medicare Advantage, it is an outright misrepresentation. The benefits are vision benefits, dental benefits, and the kinds of preventive medicine, such as the mammograms, the PSA tests, and other types of things we have found that help you to dramatically increase your health, if you pursue these kinds of preventive medicine options. They are the ones that will be deprived through these benefits.

Yes.

That is absolutely true. Taking a couple of other States, California is 68 percent; Arkansas, 40 percent; New York, 69 percent; New Mexico, 65 percent. The list goes on. The point here is this: The CBO Director made it clear that these will be benefits Medicare Advantage holders will be losing.

I want to move on to some of the other reductions in Medicare. The argument being made by the proponents of this bill is that we can cut $500 billion out of Medicaid and not impact anybody's benefits or the quality of the medical care they are receiving. That is not true. Where are the other cuts, non-Medicare Advantage cuts, coming from? They come from home health agencies, hospice, skilled nursing facilities, hospitals that provide care to seniors, and other Medicare providers in what is called the market basket.

You might say we can just continue to cut the compensation or the allocation of return for procedures and health care provided in these medical providers' services and not have any impact. The reality is far from that. What will happen is this. I will give a couple of specific examples. In general, what happens is, when a home health agency or a skilled nursing facility or a hospital receives these massive reductions of over $100 billion worth of cuts in these areas, they have to adjust somehow. Let me give you some examples. The adjustment is this: In some cases, providers simply stop taking Medicare patients because they can no longer make a profit. In that case, the Medicare population loses access because they have fewer providers from which to choose. In other cases, they reduce services or reduce employees. Again, both the quality and the quantity of health care services to seniors is reduced.

Let me give some examples. A few weeks ago, I spoke to Gary Thietten of Idaho Home Health and Hospice about the impact of Medicare cuts to home health and hospice providers, which is his business. He described to me just how bad the fiscal situation has already become for home health, hospice, and other Medicare providers in Idaho.

Idaho has already lost nearly 30 percent of its home care providers. Let me repeat that. Already, it has lost nearly 30 percent of its home health care providers. They are going out of business because we are squeezing them down so tight. And that included Idaho's largest provider. The providers that are still in business are working under the same Medicare reimbursement levels they received in 2001--8 years ago. If the kinds of cuts contemplated by this legislation go into effect, on top of the current reimbursement issues, the situation will get worse.

Gary said that he compared this situation for home health and hospice providers to the farmers in Idaho. He said that most farmers don't grow just one crop. Similarly, home health agencies do more than just provide home health; they provide hospice and private-duty care along with medical supplies and equipment. All of this will get reduced.

Let me give another example. Robert Vande Merwe of the Idaho Health Care Association talked to me about the impact of these cuts on skilled nursing facilities.

Skilled nursing facilities, such as the hospice facilities, already face a budget challenge under recent CMS rules restricting their compensation for the services they provide. The cuts they have already received, not counting what will come at them in this bill a hundredfold more, have already caused a reduction in reimbursement in Idaho by over $4 million per year to skilled nursing facilities.

He pointed out to me that in the nursing home world, more than 70 percent of the expenses they have are labor, primarily nurses and nursing assistants. He said when payment cuts like these occur, they cannot go to their buildings and take bricks out of it. What they have to do is reduce their employment. That cuts employees. That cuts benefits and services to those who are there.

Let me make this clear. First of all, these cuts are going to reduce jobs and, secondly, they are going to directly tie to the quality and number of staff there to provide care for those in the Medicare system.

Yes.

Mr. President, I appreciate that question, who are the providers. If this Medicare beneficiary is in a skilled nursing facility, the provider is the facility itself, which I said we already lost 30 percent of our facilities. It is the nurses and the nurse assistants who are there to assist them and care for them.

The bottom line is, you simply cannot cut hundreds of billions of dollars out of these services and expect to provide the same level of access and quality and available health care.

The same would be true if the care were being provided in a home setting, which a lot of the home care services are compensated by Medicare or in a hospital which is there to provide care in some of the most serious types of circumstances. Whatever it is, whether it is home hospice care, skilled nursing facility, a hospital or what have you, what we see is a reduction in the number of facilities and personnel available, and that is nothing other than rationing.

It is a different kind of rationing than will occur under some other parts of this bill where the government will actually get in the business of saying what kind of health care you can get and at what time in your life you can get it. But it is a kind of rationing that simply forces the availability of health care down so far that the system itself rations it out.

Yes.

The Senator is absolutely correct. I will comment on that and then conclude and turn the floor over to my colleagues from Mississippi and Florida for their comments. That is exactly right. In fact, one of the most clear and obvious places in which

this legislation violates the President's pledge--that if you like what you have you can keep it--is in Medicare Advantage because one out of four Medicare beneficiaries in America will not be able to keep what they have and will see their benefits cut.

There are also other parts of this bill that impact people outside of Medicare in terms of the kind and quality and extent of health care insurance coverage they have and expect that will be impacted. It would impact beyond this. This is about as clear a case there is of violating that promise.

The Senator is correct. I will conclude with this. I think we have all seen folks are almost falling over themselves backing away from the news on the mammograms that came out. But it is a very clear example in a way a study can come out from a government source or otherwise to say we don't need to have this kind of health care in the United States, it is a cost saving. What do you think is the potential for this commission to say: We are charged with saving costs in these programs, and we are going to do that.

I suspect that the mammogram issue is one they would not do it on today because of the reaction to it. Somewhere this commission is going to save tens of billions of dollars, in addition to these kinds of cuts, by reducing services. Color it as you want, you cannot make this kind of reduction of health care services, personnel, and infrastructure without reducing the access to and the quality of care that Americans receive.

I will conclude by saying these issues face every State in America. We are going to see in this arena a dramatic reduction of the quality and content and quantity of health care that our Medicare beneficiaries today see because of these proposals, and they are being done not in order to make the Medicare system more solvent but to finance yet another major Federal entitlement program that will cost hundreds of billions of dollars. As a matter of fact, if you look at the true numbers, the cost will be over $2 trillion in a full 10-year period of time.

There is a lot more we could say, but I know my colleagues from Mississippi and Florida have some remarks they wish to make. I yield to them at this time.

The Senator is right. As a matter of fact, if I understand the

legislation correctly, it assumes the current projected cuts for physicians are going to happen. That is how it says it is not going to increase the deficit. You and I both know this Congress will not let that happen.

But even today, 29 percent of Medicare beneficiaries looking for a primary care doctor had a problem finding one because, both with regard to Medicaid and Medicare, because of the problems we have been discussing here, there are fewer and fewer providers who will take patients in those programs.

Mr. President, I would like to focus my remarks today on health care as many others have done. Actually, I am very glad to see the debate today was focused on small businesses and the impact of what we do on them.

I am surprised, however, to see those who are discussing the current legislation that is before us are discussing it as something that will benefit small businesses and will help to drive down the cost curve because, as remarkable as it may seem, this legislation that both the House and the Senate have had under consideration--hopefully what we will now see in the near future as the final product that we will be able to review--will drive up the cost curve and increase the cost of health care, not only for small businesses but for everybody in America.

If we ask most Americans what they want in health care reform, they will tell us they want to stop the spiraling cost of health care insurance. Yet the legislation we see does exactly the opposite. Over the last few weeks I have come to this floor to discuss tax increases that were contained in the health care legislation passed by the Senate Finance Committee, both in terms of the big picture and, more specifically, in terms of what it means to middle-income Americans and to small businesses and to any American who wants to answer the question: How would this bill affect me and my family?

We have already heard the answer to that question in a number of different contexts, but I think it bears repeating. Under the Senate Finance bill, if you have insurance, you get taxed. If you do not have insurance, you get taxed. If you don't want to purchase insurance, you get taxed. If you have a job, you get taxed. If you need medical devices, you get taxed. If you take prescription drugs, you get taxed. If you have high out-of-pocket medical expenses, you get taxed.

The list goes on. The reason is this legislation will create new, brandnew massive entitlement programs to the tune of what we do not clearly know yet but which will almost certainly be in the neighborhood of $2 trillion. It pays for them--or offsets the cost of those on the Treasury--by increasing taxes on the American people by hundreds of billions of dollars and by cutting Medicare by hundreds of billions of dollars.

We still do not have the ``merged'' Senate bill before us to review and debate, but we do have the House-passed bill to review. There have been a number of rumors and discussions in the media about what kind of new tax increases the Senate bill will have when it is finally disclosed. In fact, we hear we may find out, as a country--the people of America may find out tonight what this bill that has been negotiated and created behind closed doors actually contains. I would like to take a few minutes to review some of the provisions that we expect to be there.

The House version of the health bill contains more than $752 billion of tax increases. Some of these tax increases are the same ones we have already seen in the Finance Committee bill, such as the medical device tax, the $2,500 cap on flexible spending accounts, the prohibition on prepurchase health care accounts--FSAs and HRAs--and the doubling of tax penalties for those in emergency situations who must use a portion of their health savings account to pay for nonmedical bills.

There are many other new tax increases in the House bill which we have not seen in the Senate finance bill that we also need to review. From the beginning of this process the chairman of the Finance Committee has stated his intention to use only health-related offsets to pay for health-related spending. If there is to be new health- related spending, that is definitely the right approach. We all know what a difficult circumstance our country faces today when it comes to jobs. The current unemployment rate is 10.2 percent. The last thing we need to do is to enact policies that would make it even tougher for U.S. companies, particularly small businesses, to create new jobs. But, amazingly, the House bill contains more than $80 billion in tax increases on domestic U.S. job-creating companies that have no involvement in the health care industry.

Not only do these provisions violate the idea that we should be staying within the health care arena to find offsets on the health care bill, but these antijob tax increases are the last thing we need in this fragile economy. The largest tax increase in the House bill would also have a devastating effect on the job creators in our country, particularly small businesses, that are the top job creators. This $460 billion so-called ``millionaire surtax'' is bad policy for many reasons.

First, like the $80 billion tax increase on domestic companies that I just mentioned, this tax increase grabs hundreds of billions of dollars from outside the health care arena to pay for a massive expansion of a new health care entitlement.

Second, although this provision is being billed as a tax increase on millionaires, the Joint Tax Committee reports that one-third of the revenue it will generate is not from individual income of millionaires but from small businesses. As we know, many small businesses file their taxes as individuals, and it would be these small businesses, the job creators of our economy, that would be facing this new punitive surtax.

Third, although you would think we would have learned our lesson from the alternative minimum tax, like the AMT, this new surtax would also not be indexed for inflation. That means, over time, this would creep further and further down the income scale, and more and more small businesses and middle-income families would be suddenly hit by this surtax.

Fourth, this surtax would not only apply to ordinary income, it also applies to capital gains and dividend income which are currently taxed at lower rates. The capital gains and dividend rates are currently 15 percent. If Congress doesn't act before next year, the rates will go back up to the pre-2003 levels of 20 percent for capital gains and up to a maximum of 39.6 percent for dividends.

The President has said he doesn't intend to extend the current lower rates for individuals making less than $200,000 a year or for families making less than $250,000 a year. But if we add in this new surtax in the House bill, Americans above those thresholds who are currently paying a 15-percent capital gains tax rate would see their tax rate jump to 25.4 percent in 2011, and those currently paying the 15 percent dividends rate would see their rates jump to 45 percent by 2011.

Such a tax increase would violate yet another one of President Obama's tax pledges to the American people. Most of us are very familiar with his promise.

Most of us are familiar with his promise that no individual making less than $200,000 a year or a family making less than $250,000 a year would see any increase in their taxes. In fact, in his words, ``not by one dime''--not an increase of their income tax, their payroll tax, their capital gains tax. In his words, not any of their taxes. Yet we see hundreds of billions of dollars of these taxes falling squarely on the middle class. In a speech in Dover, NH, on September 12, 2008, President Obama said:

Everyone in America--everyone--will pay lower taxes than

they would under the rates Bill Clinton had in the 1990s.

This surtax clearly breaks that promise to millions of additional Americans.

Recent press reports have suggested that, in a need for even more tax revenue to pay for all of the new spending in the Senate, the Senate leader may include an increase and an expansion of the Medicare payroll tax. The Medicare payroll tax is funded by a 2.9-percent payroll tax levied on every dollar earned by employees. Half of this tax is paid by the employee and the other half by the employer, although in reality, the entire burden falls on the employee because the tax is taken from the employee's available wages. Revenue from this tax goes into the Medicare trust fund and is intended to be used for Medicare expenses when that individual enters retirement. Under this new plan, Senate Democrats are considering applying this Medicare tax to capital gains, dividends, interest, royalties, and partnerships for American families earning more than $250,000. None of this income is currently subject to the Medicare payroll tax.

In addition, Democrats are said to be contemplating raising the employee's share of this tax, currently 1.45 percent of wages, to 1.95 percent. Press reports indicate this would raise up to 40 or 50 billion new dollars in revenue. This proposal would make a bad bill even worse. It would fundamentally change the way Medicare financing occurs. By applying what has traditionally been a payroll tax to nonpayroll income and by using this money for a new non-Medicare entitlement, it breaks the link between the Medicare tax base and Medicare benefits. As the Wall Street Journal pointed out, this new tax would ``sever the link between the tax paid over a lifetime and the medical benefits received, officially making Medicare an income redistribution program.''

It would additionally hurt growth. These additional taxes on savings and investment act as disincentives for these activities which are the primary drivers of wealth creation. It would kill jobs. Imposing these new taxes would hurt small businesses. Because many small businesses pay their taxes at the individual level, imposing higher individual income taxes hurts these engines of job creation.

Finally, it doesn't fully finance health care shortfalls. According to Bloomberg, House Democrats rejected this proposal, now being considered by the Senate, ``because lawmakers concluded they may need to increase the payroll tax in the future to pay Medicare benefits that are projected to outpace revenue.'' The New York Times pointed out that ``the higher payroll tax would not be sufficient in the long run [to even protect Medicare].''

In closing, for all the talk about this need to rush the bill through so we can achieve the objective the American people seek in health care reform, the bill does not reduce the cost of medical care. It increases it. The bill does not reduce the cost curve for health care insurance. It increases it. And in accomplishing this, it also increases taxes across the board on Americans and cuts Medicare by deep rates that will cause Medicare to face insolvency even earlier than it otherwise would have.

For all these reasons, we need to slow down and start working together, step by step, to remember the original objective; that is, to bend the cost curve down and stop these spiraling increases in health care insurance that Americans are facing and that are driving American families to the edge.

I yield the floor.

I, too, would like to talk about health care. As we speak here in the Senate, the House is preparing to debate and reportedly vote by late this week or early next week on a massive new health care bill that will dramatically expand the size of our government, dramatically increase taxes, and establish a government-controlled insurance system.

While in the Senate we are not yet clearly aware of what the bill we will be debating is because it is still being crafted behind closed doors, we have an idea, and we are pretty sure some of the elements that are going to be included in it are the same elements we debated in the Finance Committee and the HELP Committee as those committees worked on their product here. In that context, we expect we will see also here in the Senate a massive new expansion of the size of government, up to $1 trillion or more. If it is anything like what the Finance Committee bill was, we will see taxes increased on the American public by over $500 billion, we will see cuts in Medicare, which we discussed yesterday, of over $400 billion, and a significant expansion of the control of the Federal Government over our health care economy. Today, I want to focus on just the tax piece of this situation.

One of the most common provisions we have seen here in the Senate that we clearly expect will be in the final bill is the proposed 40- percent excise tax on high-cost or ``Cadillac'' health care plans. This has been defined as health care plans that are valued at more than $8,000 for an individual or valued at more than $21,000 for a family.

It is important to note these thresholds are not indexed to the increasing cost of health care spending but instead are indexed to inflation plus 1, which means that over time this will, similar to the alternative minimum tax, eat further and further into the American public's health care plans, which will then be taxed.

The Joint Tax Committee has scored this tax to generate $201 billion of revenue to pay for that portion, $201 billion of this new Federal spending proposal. Many think that because it is called an excise tax on health care plans, it is not going to impact them. They will be surprised to learn that in my questioning of the Joint Tax Committee, we were told the vast majority of this $201 billion tax is expected to be collected directly from the middle class, individuals who will be paying more income and payroll taxes.

Let's figure out how that can be. It turns out that as we analyze the way this tax is going to work, employers that will face a 40-percent excise tax on the health care they provide to their employees will begin to adjust the value of their health care plans so they avoid the tax. As they do so, they will reduce the health care they are providing to their employees and, presumably--and we expect they will--increase the wages they are paying to their employees so their employees' net compensation is not changed. The result of that, though, is that since the health care portion of the compensation is not taxed and the income portion of an employee's compensation is taxed, the employee will actually pay higher taxes, both on the income and on the payroll tax level.

Maybe a real-world example will demonstrate. In my State of Idaho, the Census Bureau says the median household income is about $55,000 per year. In this case, let's take an example of a single woman who currently earns $60,000 per year in annual compensation from her employer. We have an example represented by this chart. Let's assume she has a $10,000 valued health policy. Her total compensation package from her employer is going to be $60,000-$50,000 in wages and $10,000 in employer-provided health care benefits. She is taxed on $50,000 and gets the $10,000 health care benefit without taxation. What will happen in the bill, as I have indicated, is this $10,000 health care policy will be subject to a 40-percent excise tax. In order to avoid that excise tax, the company will simply react by reducing her health care policy to below $8,000 and increase her income.

Let's put up another chart to see what the likely reaction of the employer will be: Not to pay the insurance fee, as many here are saying, but simply to skip that and direct her tax dollars to the Federal Government. If this new high-cost plan is to be enacted, the theory is her employer will make the adjustments to change her overall compensation package in a way that she ends up with higher wages.

Let's put the next chart up to show how this would work. Under this proposal, her health care benefits are going to go down. Let's assume the company reduces her health care benefits from $10,000 in value to $6,000 in value and gives her the extra $4,000 in income. Her health care benefits will go down. She will pay more taxes because she now has $4,000 more of her package that is subject to compensation. The net value of her compensation will go down because of increased taxes. The result is, we are going to see millions of Americans pay this excise tax squarely in contravention of the President's promise that no individuals who make less than $200,000 will pay income taxes or payroll taxes or, in the President's words, ``any other kind of taxes.''

So we are clear on this, the estimates are that 84 percent of this tax is going to be paid by those who are earning less than $200,000 per year. As a matter of fact, if we look at those who make less than $50,000 a year, we expect somewhere in the neighborhood of 8 million Americans will fall into this category. If we look at the number who make less than $200,000 per year, we expect that number will be above 25 million Americans who will be paying more taxes, both payroll and income taxes, and receiving less health care benefits from their employer.

The net result is, the President's promise that one can keep their health care if they like it will not be honored because of this provision. People will see, necessarily, that their employers will begin reducing health care packages to make them fit the tax structure this bill will create.

Secondly, there is the President's promise that if you make less than $200,000 as an individual or $250,000 as a family, you will pay no taxes under this proposal. As we have seen with this one example--and there are a number of other examples in the proposal being developed-- in this one example of $201 billion worth of the new taxes in the bill, those making less than $200,000 will pay over 80 percent of it, and it will come directly out of their pockets and their compensation package with their employer.

In the time I have remaining, I wish to focus on one additional element. There is also a proposal to increase the bar for deductions of health care expenses. In other words, those who deduct their expenses and itemize their deductions can today deduct that portion of their income over 7.5 percent of their income that is represented by their health care expenses. This bill will increase that to 10 percent and generate over $15 billion of additional taxes in that format. Who is the most likely to pay these taxes? People who have relatively low health care costs are going to end up not meeting that 7.5-percent threshold, now to be brought to 10 percent, and probably will not be able to benefit from the deductibility of their health care. But those who face medical crises, those who have health care expenses that exceed the value of 10 percent, will see their deductibility reduced again by these proposals. The net result: Millions of Americans making less than $200,000 a year will pay more taxes.

I encourage the Senate, as we move forward in the debate, to recognize that the tax provisions contained in it are squarely going to hit those in the middle class.

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

Mr. President, I ask unanimous consent to speak in morning business.

Mr. President, I rise today to discuss Medicare also in the context of the proposed health care reform we are dealing with in the Senate.

This is one of the most troubling aspects of the health care reform proposals that are being considered in the Congress: the massive cuts to Medicare that will total, under the legislation that came out of the Finance Committee at least, about $500 billion in cuts and similar levels of cuts are included in all major legislation being moved at this point.

In this time of economic downturn, all Americans must look to their budgets and to their own spending very carefully. The same is true for the Federal Government.

Some will argue these Medicare cuts are necessary for fiscal responsibility and that everybody must play a part. Others are going to argue that Medicare is facing insolvency in 2017 and that these cuts are necessary to slow the growth of Medicare spending. In fact, the 2009 trustees report shows that Medicare's annual costs were 3.2 percent of the gross domestic product of the United States in 2008. To give a little bit of context, that is about three-quarters of Social Security's costs. These costs are projected to surpass Social Security expenditures in 2028 and reach 11.4 percent of GDP by 2083.

The unfunded obligation of the Medicare hospital trust fund is $13.4 trillion, which is $1 trillion higher than even last year's estimate. And Medicare's total unfunded obligations, which include Part B and Part D programs, have reached $37.8 trillion.

Yes, we do need to address the solvency issues related to Medicare. We must deal with it. But let's be clear about one thing: These proposals in these health care bills do not strengthen the solvency of the Medicare Program.

These cuts accomplish one simple goal; that is, they take money from the Medicare Program in order to create a new entitlement program. The program is created at the expense of America's seniors. We are not shoring up Medicare for America's seniors with these bills; we are transferring $500 billion out of the Medicare programs into a new government entitlement program.

A recent article described it like this: Let's imagine that Medicare is your family's overall budget. You have lived beyond your means and you have run up a huge debt. In order to deal with this new debt, your family thinks of creative ways to cut spending and reduce expenses and put some of your savings aside to catch up. Then, though, you see all this cash that you saved up and you would like to go out and buy a brandnew car. So instead of using the cash to help pay off your debts and your obligations and shore up your financial circumstances, you take this cash and go out and spend it on a brandnew car, in this case a government-run car.

This is what is happening with the Medicare system in the bills before us. These cuts damage the existing program in order to create a new one, harming America's seniors along the way. They are negatively going to impact choice, access, benefits, and quality of care. When Americans said they wanted change, I don't think this is what they were talking about.

Let's talk about a few specifics.

Among the largest cuts to the Medicare Program are the $117 billion in cuts to the Medicare Advantage Program. Currently, there are nearly 11 million seniors enrolled in Medicare Advantage, which represents about one out of every four Medicare beneficiaries. In my home State of Idaho, there are more than 60,000 Medicare Advantage beneficiaries or 27 percent of Medicare beneficiaries in the State.

Since the creation of the Medicare Advantage Program in 2003, overall enrollment in private plans has been steadily increasing and beneficiaries across the country have had more private plans to choose from than they did 10 years ago.

A 2007 study reported ``high overall satisfaction'' with the Medicare Advantage Program. Mr. President, 84 percent of respondents said they were happy with their coverage, and 74 percent would recommend Medicare Advantage to their friends or family members.

According to Congressional Research Service, as of January 2009, all Medicare beneficiaries across the country had access to Medicare Advantage plans along with traditional Medicare plans. The choice is particularly crucial in rural areas. Between 2003 and 2007, more than 600,000 beneficiaries in rural areas joined the Medicare Advantage Program, which is a 426-percent increase.

The Medicare Advantage cuts proposed in the Finance bill will force plans to cut benefits, increase premiums, or drop coverage altogether. In fact, CBO estimates that enrollment in Medicare Advantage will decrease by 2.7 million people by 2019, resulting from the changes in this proposed legislation.

This number represents not only people who would lose their plan but also those who would no longer be able to choose Medicare Advantage because of the decrease in benefits.

CBO estimates that the value of extra benefits offered by Medicare Advantage plans will drop from $135 a month to $42 a month. When we were in the Finance Committee markup, I asked CBO Director Elmendorf to confirm this point. I asked him:

So approximately half of the additional benefit would be

lost to those current Medicare Advantage policyholders?

His response was:

For those who would be enrolled otherwise under current

law, yes.

The point is, the Medicare Advantage cuts in the Finance Committee bill will clearly break the President's pledge that if you like the insurance you have, if you like the protection you have, you can keep it.

Even if some seniors on Medicare Advantage are able to keep their plans, they are not going to be able to enjoy the same level of benefits they enjoy today. During the Finance Committee markup, I offered an amendment that would have prohibited the implementation of the bill's Medicare Advantage provisions if their implementation would decrease choice and competition for seniors in Medicare--very simple and straightforward. The amendment was defeated on a straight party- line vote.

Many congressional Democrats argue that by defending Medicare Advantage you are actually defending overpayments to insurance companies. That is not true either. Medicare Advantage plans are paid 14 percent more, on average, than traditional Medicare fee-for-service. However, these overpayments--or alleged overpayments--don't go into the plans. They go to the seniors enrolled in the plans in the form of extra benefits. That is why Medicare Advantage is so popular among seniors. Seventy-five percent of the additional payments to Medicare Advantage are used to provide seniors with additional benefits-- benefits such as dental coverage or vision coverage or preventive medicine or flu shots or hearing aids. The remaining 25 percent is returned to the Federal Government. So the cuts to Medicare Advantage will reduce benefits and will deprive seniors of choice.

But that is not the only kind of cuts we have coming to Medicare. In addition to the cuts to the Medicare Advantage Program, the Finance Committee bill also contains massive cuts to other Medicare providers. It contains $40 billion of cuts to home health agencies, there are nearly $8 billion of cuts to hospice, and more than $16 billion of cuts to skilled nursing facilities. These levels of cuts would be devastating for providers and will threaten access as well. As more and more providers will not take Medicare patients, it will be harder and harder for beneficiaries to find care.

I spoke to Gary Thietten, the president and owner of Idaho Home Health & Hospice, just last week about the impact of the Medicare cuts to home health and hospice. He described to me how bad the fiscal situation has become for home health, hospice, and other Medicare providers in Idaho. Idaho lost nearly 30 percent of its home care providers in 1998 and 1999, including the State's largest provider. The providers that are still in business in my home State are working under the same Medicare reimbursement levels they received in 2001--8 years ago. If the cuts from the Finance Committee bill go into effect, on top of the current reimbursement issues, the situation will get significantly worse for many providers, and the net result, again, would be a loss of providers, a loss of options, and a loss of services to our seniors.

Costs have gone up considerably due to the economic downturn, and rural Idaho is being hit the hardest. Gary compared the situation for home health and hospice providers to the farmers in Idaho. Most farmers don't grow just one crop. Similarly, home health agencies don't provide just one service. They provide hospice and private-duty care, along with medical supplies and equipment. All of these services are going to suffer because of the home health and hospice cuts.

These proposed cuts will not just affect providers in my home State, they will affect Medicare providers in every State around the country, particularly rural States, which already face significant provider access problems. At some point, providers will no longer be able to give the best care or any care, for that matter, to Medicare beneficiaries. As I indicated earlier, we have already seen the trend start with those medical service providers that simply can't afford to take Medicare patients.

I have long supported policies that increase access to high-quality affordable health care for all Americans and provide for fair reimbursements to providers of the medical services rendered. However, the types of blunt, across-the-board cuts we see in these proposed bills will result only in increased harm to providers and to Medicare beneficiaries around the country.

It is my hope that as we face these difficult times, and dealing with needed health care reform, we will not take the cuts out of the Medicare Program that are proposed in this legislation. Specifically, and importantly, it is critical that we not cut our Medicare beneficiary services in order to simply fund a new, massive government entitlement program.

With that, I yield the floor.

Mr. President, I ask unanimous consent to speak as in morning business.

Mr. President, I wish to talk this afternoon about health care and specifically the impact of some of the proposals we have on the cost of health care insurance. Before I do so, I think I must respond to some of the comments that were just made by the Senator from Michigan accusing the Republican Party of being the party of no. It seems we are starting to get to a point here where bipartisanship is not being achieved. But it seems the definition of bipartisanship is becoming ``either do it our way or you are the party of no.''

It seems to me what we need to really do is step back and take a couple of deep breaths and start working together on legislation. I will use the example the Senator from Michigan used, the unemployment insurance compensation legislation. As she correctly indicated, there were 87 votes to move forward with this legislation. This is not an effort to obstruct the legislation. The effort that caused us to slow down a couple of days on this legislation was an effort to improve it. In fact, had we not slowed down a couple days, the bill would have gone through and would have been passed, but it would not have the home buyer tax credit in it for the purchase of homes. It wouldn't have the net operating loss carryback provisions in it. They are both important provisions for creating jobs rather than just providing a safety net for those who lost jobs. The bill has been improved, and I think it will be further improved by the time we have the final vote.

It is that process of give-and-take, trying to work on and improve the legislation, that occasionally causes the Republican side to say: No, we are not going to move forward until we have an opportunity to present some amendments and until we have bipartisan work to help improve the legislation. That is what happened in this case.

In reality, the majority party has 60 votes. If they want to proceed on anything, they can do so. In this case, on the unemployment insurance bill, they did stop and allow us another couple of days to work on it and improve it with the home buyer tax credit and the operating net loss carryback provisions.

Mr. President, I will now address the question of health care. It is interesting. One of the comments the Senator from Michigan also made was that we cannot get to the health care bill because we are spending our time on the unemployment compensation bill. The reality is that we don't even know what the health care bill is yet. The bill was crafted behind closed doors in the Capitol Building, and it is being scored by CBO. We don't know when CBO will have the full bill to score or whether the full bill has even been drafted. We don't know what it contains.

That is in stark contrast to the President's commitment on how this process would proceed. The President stated in the San Francisco Chronicle in January of last year:

These negotiations will be on C-SPAN . . . and the public

will be part of the conversation and we will see the choices

that are being made.

He indicated that everybody should be in the room and it should be broadcast on C-SPAN. Instead, there is a very small group of people from the White House and the majority leader's office and probably a couple of senior Senators he is working with who know what is in the bill. The rest of us don't know.

Frankly, the reason we are not moving to the bill has nothing to do with procedural maneuvers on the floor. It has to do with the fact that the bill is not drafted yet or prepared and ready to bring forward.

Let me move to the actual bill itself. In this context, I have great concerns

with the legislation that is being brought forward on many different fronts. It expands the Federal Government by about $1.2 trillion, depending on how you count it; some say up to $1.8 trillion. It imposes massive new taxes and cuts in Medicare of equal amounts to balance it off and make it appear it is not increasing the deficit. By cutting Medicare, it seriously jeopardizes the quality of health care we provide to our seniors in this Nation and, as I indicated, the massive new taxes that are involved, which fall squarely on the backs of the middle class, violating another one of the promises President Obama made. In doing so, it does not achieve the very objectives our citizens in the United States ask of us in health care reform.

What am I talking about? That is what I want to focus the rest of my remarks on today.

When you ask most Americans, Do we need to reform health care in the United States, they will say yes. What they mean when they say that is they are tired of the double-digit, skyrocketing inflation of the cost of their health insurance and the cost of medical care in the United States, and they think Congress should do something about it, that Congress should ``bend the cost curve down''--that is the phrase that has been made popular--and they believe Congress can do something about it and help control these skyrocketing costs of health care.

They also believe we should try to find a way to get access to those who are needy and unable to purchase their own insurance. They know we are providing for the cost of health care for those who do not have insurance and they do get it in a much more expensive way and in a way that does not give them the quality of health care they should get. That is what Americans think of when they are asking for health care reform. But center in the focus of the American people out of what they want out of health care reform is control of the costs of health care and control of the skyrocketing costs of the insurance they pay.

On that issue, the bills before us fail dramatically because not only do they grow the Federal Government, not only do they increase taxes, and not only do they deeply cut Medicare, they will increase the cost of health care insurance and increase the cost of medical services in our country beyond what growth they would have seen without the legislation.

I will go through a couple of examples, focusing on the bill that went through the Senate Finance Committee. It includes, as I have indicated, significant amounts of taxes and different kinds of taxes on different parts of the economy. Both the nonpartisan Congressional Budget Office and the Joint Committee on Taxation have stated that a number of the taxes included in the Senate Finance Committee bill will be passed on to consumers in the form of higher premiums.

During the Finance Committee markup, CBO Director Douglas Elmendorf stated:

Our judgment is that that piece of legislation--

Referring to the provisions increasing taxes in this legislation--

would raise insurance premiums by roughly the amount of the

money collected.

Meaning in one of the particular cases there is a $6.7 billion tax imposed on insurance companies. His point is that $6.7 billion tax is going to raise the cost of insurance.

Another example in the bill, there is a tax on medical devices. Both CBO and JCT have said this tax on medical devices will be passed on to patients, increasing their health insurance premiums and increasing the prices on everything from powered wheelchairs to pacemakers.

Another example is the tax on insurers. I mentioned the tax on insurers is what generated this answer. CBO and Joint Tax have said this tax will be passed through, and some estimates on this passthrough show this tax on insurers could raise premiums for American families by as much as $500 a year.

The Congressional Budget Office sent a letter to Senator Grassley last week in response to his inquiry about this provision and stated:

While uncertainty exists, we assume that a very large

portion of this excise tax on purchased insurance will be

borne by consumers in most markets, including in some markets

with a high level of concentration among market participants

covered by the proposed excise tax.

Still quoting the letter:

While consumers or employers may respond by changing their

insurance coverage from more expensive coverage to less

expensive plans to offset any potential price increase, this

behavior, too, is properly characterized as the consumers

bearing the burden of the excise tax by accepting lower

quality (for example, a more restricted physician network)

for the same price rather than paying a higher price for the

quality [that they would have had had there been] no tax.

Again, still quoting from the letter:

Our estimate is that the premiums for purchased health

insurance policies, including the tax liability, would be

between 1.0 and 1.5 percent greater than they otherwise would

be as a consequence of the industry fee for calendar years

2010, 2011, and 2012.

Joint Tax did not estimate the years beyond that and were not able to do a distributional analysis based on income as to where those with higher premiums would most likely fall. But we know, again, it is almost certain it will hit those in the middle class.

Premiums are also going to rise because of the new excise tax on so- called Cadillac health plans. Many believe that companies will respond to this new tax by either passing the costs on to consumers or cutting benefits so the plan can avoid the tax. Inevitably, like the AMT, the alternative minimum tax, the impact of this tax will be passed along to more and more people, not just those with Cadillac plans, either in the form of higher costs or lower benefits.

That is how the tax-and-fee provisions portion of the bill impact health insurance. And there are many more. But what other provisions in the bill impact the cost of insurance? The insurance mandates in the bill will have similar impacts on raising the cost of health care insurance for Americans.

The Finance Committee bill also contains a number of market reforms that will result in these higher premiums. For example, the new federally mandated rating rules will result in a huge premiums increase for younger and healthier individuals.

In my home State of Idaho, studies have shown that a 20-year-old male can go out today and buy a policy in the individual market for $67.63 a month. A 20-year-old female can buy a policy for $94.35 a month. If the insurance rating reforms in the Finance Committee bill are enacted, those exact same policies would rise to a level of $166.75 per month. That is a 147-percent increase for a 20-year-old male and a 77-percent increase for a 20-year-old female.

These figures, frankly, are optimistic for several reasons. They assume that the young and healthy will continue to purchase insurance. If they do not continue to buy insurance, the premiums would likely be even higher than those which were shown in the studies.

In addition, these rate estimates assume a 4-to 1 age rating band. The House bill introduced last week contains a 2-to-1 age rating band mandate, meaning that the rates for the young and healthy, again, would be made significantly worse.

In addition, many of the proposals in Congress contain mandates about what an insurance policy must include. Here is an example of what we can see in that context: An older gentleman wanting to purchase insurance in the new exchange to be created may not be able to save money by enrolling in a more basic plan. Instead, it would not be possible for him to enroll in a policy that does not include maternity care and newborn care, something he may not want or need to purchase.

The actuary firm of Oliver Wyman, in a study commissioned by Blue Cross/Blue Shield, concluded that insurance reforms in the bill and the minimum required benefit levels in the Baucus bill could drive up family premiums for new coverage by as much as $3,024.

My point is, both the taxes and fees and the insurance mandates will generate higher premiums, not lower premiums, for Americans, exactly the opposite of what Americans are asking for in health care reform.

Similarly, both the House bill and the Baucus bill, and what we expect to see in the Senate bill when it finally comes out, will have a significant expansion of moving those in lower income categories into Medicaid rather than providing a way for them to obtain insurance.

The Baucus bill contains an enormous expansion of Medicaid, up to 133

percent of poverty. That means 14 million more people are going to be enrolled in the Medicaid Program, the largest expansion since it was created in 1965, a program that financially is going to hit the cliff soon. We know we are undercompensating for medical services in Medicaid, which ultimately results in those undercompensated costs of health care being borne by the rest of the insuring population in the United States with higher premiums.

So what are we going to do? We are going to expand a program that drives a lot of its costs off onto the private sector so we can avoid the need to identify the way to move forward and develop a true reform that will enable those who are needy and uninsured to be able to obtain insurance. Instead, we are going to push them onto the Medicaid system and, again, drive up premiums.

Those who are pushing this legislation have responded to some of these arguments by saying: The subsidies we are providing in the bill for those with lower incomes will help to reduce insurance costs. If you focus on those who receive the subsidies, of course, their insurance costs may go down. But this is true for only a very small number of Americans.

The reforms in the Finance bill will raise health care costs for most Americans while lowering them for some through subsidies. But there are several important points to make on the subsidy argument.

First, the credits and subsidies are only available for those who receive insurance through the new exchange. In other words, if you get your insurance through your employer, which most Americans do, you do not qualify for any subsidy support.

CBO has estimated that only 23 million Americans will receive insurance in that fashion. If you do the math, that represents 8 percent of the 282 million nonelderly Americans. Why do we take the nonelderly number? Because elderly Americans are covered by Medicare.

Let's put up a chart. The subsidies are not available for individuals who get insurance through their employer and, instead, those individuals will pay higher premiums for those who receive the subsidies. Here is the way it works out. You have about 185 million Americans who will be paying more taxes and higher health care premiums, and about 18 million Americans who will actually see their health care premiums go down because they will receive a Federal subsidy.

While it is true that the subsidy will help reduce the health care costs of those who receive it, it is not true that the health care costs for every other American are going to go up, again I want to point out, in two significant ways. The 185 million Americans who are not participating in the subsidy will pay more in taxes--and significantly more in taxes--and will pay more in their health care insurance premiums. That is not the kind of reform, again, that the people of the United States are asking for.

One last point, and that is about this proposal to have the Federal Government step in and create a government health care company. A government-run health care insurance company is promoted by saying we need a competitor for the private sector. I think most Americans see through that. But last week, CBO released their score of the House bill which creates just such a government-run health care company. Their score shows that the new government plan would typically have premiums that are higher than the average premiums for private plans.

What is CBO saying? The CBO letter then states that although the government plan would likely have lower administrative costs than the private plans--which is one of the key arguments that is often made-- the government plan would--and I am quoting from CBO--``probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees,'' resulting in higher premium costs in the government plan.

So now what do we have? We have a government plan into which we are going to push a lot of Americans, unwillingly, which will charge higher premiums than the private sector. We have taxes, penalties, fees, and mandates being imposed on the private sector that are going to drive up their premiums as well. It is all justified by the argument that we need to somehow create a government control of health care so we can reduce the costs. There are other ways to reduce the costs. I don't have time in my remarks today to get into those, but there are a number of proposals we do know about for which we have bipartisan support that will help us address that cost curve.

It is my hope we will reject these proposals that take us down the wrong path and result in the wrong solutions for Americans in health care reform and begin focusing on what I started out with--that cost curve about which most Americans are so concerned. We can drive down that cost curve without raising taxes, and that is where this Congress ought to be spending its attention.

With that, I yield the floor.

Mr. President, I ask unanimous consent that an intern from my office, Matthew Spencer, be granted floor privileges.

Madam President, I also rise to speak about the health care legislation the Senate is preparing to consider on the Senate floor. I will begin my remarks, as my colleague from Georgia has done, by referring to the bill which the Finance Committee has put out. This is it. It is 1,502

pages which, interestingly, we did not have before us when we considered it in the Finance Committee.

I think most people in the country realize right now that as the Finance Committee proceeded through 2 full weeks of markup on this legislation, the legislation had not actually been written. Even though the very first amendment, which we brought, was an amendment to say that before we would be forced to vote on a bill, we should see the bill for 72 hours and have the CBO, the Congressional Budget Office, score on the bill for 72 hours so that we and the American public could understand what was in it, that was not allowed. We cast our final votes in the Finance Committee on the Finance Committee's bill--well, the Finance Committee's concept paper. This bill didn't yet exist. We did have an idea about what concepts were intended to be in it, but the bill itself didn't exist.

The reason I bring that up right now is because this is actually not going to be the bill we consider on the Senate floor. As soon as the Senate Finance Committee finished with this bill, the majority leader and the chairmen of a couple of the relevant committees--I presume with some personnel from the White House--got together behind closed doors in the Capitol Building and began drafting a new bill to merge this bill with a previous bill that had come out of the HELP Committee bill in the Senate. That new bill has now been sent to CBO for a score, but we don't know what is in it either.

In fact, we are told it is concepts and options that are being submitted to CBO. I am not even sure if that new bill has yet been written, but I do know no one, except those who have submitted it to CBO, know what is in it.

Well, we have a good idea of what is in the health care bill the Senate Finance Committee put out, and I expect a lot of what was in this Senate Finance Committee bill will make it into this new bill that someday maybe the American public and the rest of the Members of this Chamber will be able to see. As we approach the health care issue, I think it is important for us to understand exactly what it is we are expected to do by the American people and what it is we are doing with the health care legislation.

Most Americans want health care reform. But when they say that, the vast majority of them mean they want Congress to take swift and decisive action to bring under control the spiraling costs of health care and the spiraling costs of health care insurance. As a part of that, they want to see increased access for those who are uninsured, whose burden of coverage and health care falls on the taxpayers. That is the core focus, the purpose behind the drive in America for health care reform.

Well, what does the legislation we passed out of the Finance Committee do? With regard to the cost of insurance, it will not cause the cost of insurance to go down. It will, in fact, drive up the cost of insurance at even faster rates of growth than would have occurred without the legislation. What does it do for coverage of those who are uninsured? It establishes an extremely expensive new government program that would provide tax credits--or what are called renewable tax credits--for those at certain income levels to provide the ability for them to obtain coverage. But of the 47 million who are uninsured in the United States today, the bill still leaves approximately 25 million of them uninsured.

What it does put into place for these two outcomes on the major reasons for reform--increased cost of insurance and only about 50 percent reduction of the uninsured--is a massive new amount of Federal control over the health care industry, a massive new entitlement program that will cost, according to CBO, approximately $829 billion of new spending, and then offsets that try to address the growing costs of the Federal Government that it represents by about $404 billion worth of cuts in Medicare and $506-or-so billion of new taxes, fees, and penalties.

Remember the discussion I started with about the fact that the American people wanted to see the cost curve on health care bend down? We will hear it said that this bill bends down the cost curve. Well, it doesn't bend down the health care cost curve, and it doesn't bend down the health care insurance cost curve. All it does is try to address the impact of the phenomenal amount of new spending--$829 billion--by raising taxes and cutting Medicare in amounts that are greater than the amount of the cost in the bill.

Well, what kind of impact will these increases in taxes have? First and foremost, I want to return to what my colleague, Senator Grassley, recently pointed out. In the discussion of this issue, President Obama made it clear as a candidate, and he has repeatedly made it clear as President, that he will not sign legislation that imposes a tax increase on people making less than $250,000 in the United States. These are his remarks on September 12 during the campaign in New Hampshire, which, again, he has repeated consistently:

And I can make a firm pledge: No family making less than

$250,000 will see their taxes increase--not your income

taxes, not your payroll taxes, not your capital gains taxes,

not any of your taxes.

Well, what does this bill do? This bill squarely increases the taxes on the middle class in the United States. The full tax burden of this bill, including all of the taxes and fees and penalties that are included in it, is over $\1/2\ trillion. Experts have now told us that the majority, in fact the significant majority of those taxes and those increased fees and penalties, will fall on the backs of those who make less than $250,000. We don't have the data yet, but, in fact, the impact on people who make less than $120,000 will be a huge portion of these new taxes and fees. Yet how can that be allowed to happen with the President making this pledge?

I think the American people need to pay attention. In essence, what we have represented is a huge increase in spending in the Federal Treasury--$829 billion under the Finance Committee plan. It is expected to be closer to $900 billion under the plan that was devised recently and submitted to CBO. Nonetheless, it is a massive increase in Federal spending, matched by equally massive cuts and tax increases--cuts in Medicare and tax increases--to make it appear that the impact on the deficit is marginal. But don't be fooled. When those who support this approach defend it, they will tell us it bends the cost curve. The cost curve they are talking about is the cost to the Federal Government. They are not telling us the cost of the Federal Government--the expenditures of the Federal Government--will be going down. What they are telling us is the expenditures will not be going up faster than the taxes and the cuts in Medicare are going up.

It is important for the American public to recognize that this legislation represents yet again one huge step of the Federal Government into management and control of the health care economy, and that huge new step of the Federal Government into management of the economy will be financed squarely on the backs of the middle class with a huge tax increase. That is not what America was asking for.

So to summarize, Madam President, what do we have? We have a proposal that will not bend the cost curve; it will, in fact, cause the cost curve on which everyone in America is focusing--the cost of health care and the cost of insurance--to go up. It will not achieve universal coverage for those who do not have access to insurance today, but it will put the Federal Government much more in charge and control of our health care economy and will grow the Federal Government by nearly $1 trillion of new spending at the expense of $\1/2\ trillion of tax increases and $400 billion of Medicare cuts.

That is not the kind of health care reform our Nation needs. It is not the kind of health care reform the American people have asked for. We should change the debate, and we should begin focusing on those kinds of common ground areas that we know how to identify where we can bend the cost curve--the true cost curve--down, where we can do so without raising taxes on the American people, and we can do so without devastating the Medicare programs of our country.

With that, Madam President, I yield the floor.

Mr. President, today I am proud to honor and congratulate Idaho resident Dr. Forrest M. Bird for a lifetime of service and achievement. I had the pleasure today of meeting with Dr. Bird and his wife Pam, and very much enjoyed that short visit. Dr. Bird is well and widely known around the world for his lifesaving inventions: the Bird Mark 7 respirator, which was the first reliable and low-cost respirator in the world; and the Baby Bird respirator, which has greatly decreased infant mortality rates. In addition to being a brilliant inventor and scientist, Dr. Bird is a former pilot and founder of the Bird Aviation Museum and Invention Center, which is located in Sagle, ID, where his company, Percussionaire Corporation, produces his lifesaving medical devices. He has been the recipient of numerous awards, including two Lifetime Scientific Achievement awards, and has been inducted into the National Inventors Hall of Fame. In 2008, he was awarded the Presidential Citizens Medal by President Bush and received the National Medal of Technology and Innovation by President Obama just this week.

Dr. Bird's interest in aviation and his invention of the world- renowned Bird respirators are remarkably intertwined. His father served as a pilot in World War I, and, after earning a degree in aeronautics, Dr. Bird served as an Army Air Corps pilot in WWII. At the time, airplanes were designed to reach higher altitudes, but pilots were increasingly unable to breathe as the altitude increased. Dr. Bird's consideration of this problem, and his attendance at medical school after the war, eventually led him to the invention of the famous Bird respirator. In 2007, his twin interests of aviation and invention led him to open the Bird Aviation Museum and Invention Center.

Clearly there is good reason for the impressive list of honors that Dr. Bird has received throughout his life. It has been a life of service that has made an incredible mark upon the world. His inventions have touched, transformed, enhanced and saved the lives of millions around the world. His museum provides a great service to his community by educating and inspiring young visitors and by bringing long-lost memories alive for older visitors. For his groundbreaking contributions to America and the world, Idaho is proud to have produced such an impressive citizen. We appreciate and honor his remarkable achievements.

Mr. President, today I honor a woman who has contributed so much to the fabric of my home State of Idaho. Doris Wallace, the manager of the Eastern Idaho State Fair in Blackfoot, ID, will retire at the end of this month, following the completion of the 2009 Eastern Idaho State Fair. That will mark her 26th year with one of Idaho's most well-known fairs. The eastern Idaho State Fair covers 16 counties in eastern Idaho. Each county holds their individual county fairs with the blue ribbon winners advancing to competition at the Eastern Idaho State Fair.

Doris is a hometown girl, born in Blackfoot and raised in Bingham County. She married Ray Wallace. Together they have three children: Nicole, Stephanie, and Todd.

She began her career at the Eastern Idaho State Fair in 1983 when she began working as the office secretary. She was the ``front desk'' for the fair, and her personality, patience and friendliness represented the entire fair to those who entered her office to ask questions and complain about situations.

In 1987, Doris became the assistant manager, where she became the center of the fair operations. Her responsibilities included the exhibitor's handbook, all financial transactions, commercial and concession vendors and coordinator for spring, summer, and fall events taking place on the fairgrounds.

In 2000, Doris was promoted to fair manager by a five-member Fair Board. As manager, Doris used her years of experience to enhance an already-thriving annual event. She has encouraged participation of 4-H and Future Farmer of America projects and activities including the 4-H dog show, 4-H horse show, and 4-H livestock, canning, cooking and sewing demonstration projects. Future Farmers of America leave their classrooms on Friday to spend the day on the fairgrounds to personally experience and participate in judging competitions.

In 2002, she was able to plan the celebration of the 100th anniversary of the Eastern Idaho State Fair. She produced an extravaganza of historical and colorful memories, which have made the fair a family tradition for those living in eastern Idaho.

Doris has competently managed fair operations of the Eastern Idaho State Fair, which attracts 250,000 fairgoers over the 8-day fair, beginning each year on Saturday proceeding Labor Day. Events include traditional horse pulling, pari-mutuel horse racing, Indian relay races, junior and adult rodeos, professional entertainers, petting zoos and educational exhibits. The traditional tractor pull, demolition derby, and extreme bike riders are all part of Doris's management responsibilities as she has provided a fair of diverse attractions for a fairgoing audience of diverse ages, backgrounds and interests.

As manager, Doris supervises six full-time employees and approximately 400 employees during the fair week, including ticket takers, car parkers, custodial services, ground crews, and security.

Throughout her life and particularly during her career at the Eastern Idaho State Fair, Doris has contributed enormously, both privately and professionally, to the fair community, the city of Blackfoot, and all of eastern Idaho. Please join me in congratulating Doris Wallace on her years of service at the Eastern Idaho State Fair and wishing her well in her pending retirement.

Mr. President, I rise today to discuss President Obama's nomination of Judge Sonia Sotomayor to serve on the U.S. Supreme Court.

First, I want to say I appreciate the efforts of my colleagues on the Judiciary Committee to hold thorough hearings and to process this nomination.

There is no doubt that Judge Sotomayor's resume is impressive, with degrees from Princeton and Yale Law School. She then worked as an assistant district attorney, and later in private practice before serving as a U.S. district court judge, and currently as a U.S. circuit court judge.

It is unfortunate the Senate confirmation process has reached a point where nominees with such extensive backgrounds are no longer comfortable candidly discussing their judicial philosophy and views on key issues.

To date, I have received over 1,000 letters, e-mails, and phone calls from Idaho constituents who are overwhelmingly opposed to Judge Sotomayor's nomination. Many of the concerns raised in this correspondence are similar to concerns I personally have about the nomination--concerns relating to the second amendment right to bear arms, concerns relating to judicial activism, concerns relating to whether foreign law should be utilized in interpreting U.S. statutes and our Constitution.

It was my hope that through the committee hearings and my personal meeting with Judge Sotomayor and other evaluation of her writings and her judicial decisions that these concerns and those of my constituents could be addressed. Unfortunately, though, when it came to the key issues, Judge Sotomayor's testimony often lacked the substance necessary and was even contradictory to her own previous statements, rulings, and writings.

I would like to discuss some of those areas of concern. Before I do so, though, I want to make it very clear that with this nomination, many are very rightfully proud that for the first time in our country's history we have a Latina nominated to our highest Court. And it must be noted that she is receiving and being afforded a clean up-or-down vote on the floor of the Senate this week.

As I indicated at the outset, it is unfortunate the confirmation process in the Senate has deteriorated so much over the last few years that others have not received similar opportunities. I am referring in this example to Miguel Estrada. Like Judge Sotomayor, Judge Estrada was rated unanimously ``well qualified'' by the American Bar Association when President Bush nominated him to the U.S. Court of Appeals for the DC Circuit.

The DC Circuit is often considered to be a stepping stone for Supreme Court nominations, and at that time many thought Judge Estrada would be a strong nominee, that he might be the first Latino nominated to the Supreme Court. Judge Estrada would have deserved such an opportunity as Judge Sotomayor does. Unfortunately, some on the left feared that scenario, and as a result there was a filibuster and Judge Estrada was never even allowed to have an up-or-down vote on the floor of the Senate.

I make this point now just to remind us all that although there are many here who have concerns about some of the positions and philosophies Judge Sotomayor has, there has been no effort to deprive her of an opportunity for an up-or-down vote on the floor of the Senate on her nomination. It is important our country recognize this.

Let me now turn to some of the issues I indicated earlier that are of concern. I know a number of my colleagues have spoken already about the issue of the second amendment right to keep and bear arms. That is one of my most significant concerns.

On July 27, 2008, the U.S. Supreme Court ruled in District of Columbia v. Heller that the second amendment to the Constitution protects an individual's right to keep and bear arms unconnected with service in a militia, and to use those arms for traditionally lawful purposes, such as self-defense within the home.

This ruling affirmed what common sense has told us all for a long time: that the second amendment was intended to ensure access to all law-abiding citizens for self-defense and recreation. Unfortunately, despite this ruling in Heller, Judge Sotomayor ruled in the Maloney case that the second amendment does not apply to the States.

Even the Ninth Circuit Court of Appeals, which has jurisdiction over my home State of Idaho and is often considered one of the most liberal courts in the land, has ruled the opposite way in a similar case, making it clear that second amendment rights are binding on the States.

In Nordyke v. King, the Ninth Circuit held that the right to bear arms is ``deeply rooted in this Nation's history and tradition.'' Additionally, the court found that the ``crucial role this deeply rooted right has played in our birth and history compels us to recognize that it is indeed [a] fundamental [right].''

Furthermore, and again even after the Supreme Court's ruling in Heller, Judge Sotomayor held that the second amendment does not protect a fundamental right.

With regard to whether the second amendment applies to States, I do not believe any reasonable person believes that other freedoms contained in the Bill of Rights do not apply to the States, such as freedom of religion, freedom of speech, or freedom of the press. Why is there a different standard or effort to try to keep the second amendment right to bear arms from being freely available to all individuals in the United States?

The Supreme Court has held in a series of opinions that the 14th amendment incorporates most portions of the Bill of Rights as enforceable against the States. Despite that Heller addressed firearms laws in the District of Columbia and not in a particular State, the Supreme Court used State constitutional precedents for its analysis in Heller. In fact, the Court's ruling was based in part on its reading of applicable language in State constitutions adopted soon after our Bill of Rights itself was adopted and ratified. By doing so, the Supreme Court recognized that the second amendment was, in fact, a fundamental right guaranteed under the Constitution.

On the issue of whether the second amendment right to bear arms is a fundamental right, I am extremely concerned that a nominee for the highest Court in our land would make such an argument. I am very concerned that a nominee for the highest Court in our

Nation could so construe the second amendment right to bear arms. This disregard of history and legal precedent is, to me, a clear sign of a penchant toward judicial activism.

As I have said, to reach her decision in Maloney, Judge Sotomayor had to, and did, make a judicial finding that the second amendment right to bear arms is not a fundamental right. In contrast, the Ninth Circuit Court of Appeals, in a footnote, said it as well as I think it can be said. The Ninth Circuit Court said:

The county--

Which in this case was the defendant which was seeking to implement some restrictions that were an infringement on the right to bear arms--

The county and its amici--

Those others who have filed briefs on the county's behalf--

point out that, however universal its earlier support, the

right to keep and bear arms has now become controversial.

Again, this is the Ninth Circuit Court of Appeals speaking.

But we do not measure the protection the Constitution--

The Constitution--

affords a right by the values of our own times. If

contemporary desuetude sufficed to read rights out of the

Constitution, then there would be little benefit to a written

statement of them. Some may disagree with the decision of

[our] Founders to enshrine a given right in the Constitution.

If so, then people can amend the document. But such

amendments are not for the courts to ordain.

That is the kind of correct analysis the Supreme Court has clearly guided us to with regard to the second amendment right to bear arms.

Throughout Idaho and across the United States, many millions of Americans believe the second amendment is a fundamental right, and I am one of those. Soon enough, the Supreme Court will decide whether the second amendment is incorporated by the 14th amendment to apply to the States. When that case is taken up, the Court will decide just how ``fundamental'' the second amendment is and whether States and communities can take away Americans' right to bear arms any time they want.

I cannot support a nominee to the Supreme Court who does not recognize this fundamental right in our Constitution. For this reason, I must oppose the nomination of Judge Sotomayor.

In addition, with regard to the role of a judge and judicial activism, when it comes to her views on the proper role of a judge, once again Judge Sotomayor's testimony before the Senate Judiciary Committee appears to directly contradict her publicly stated words and philosophy expressed prior to her nomination.

In 2003, when discussing her gender and heritage, Judge Sotomayor said:

My experiences will affect the facts I choose to see as a

judge.

In another previous speech, she said:

Personal experiences affect the facts that judges choose to

see.

This is simply shorthand for judicial activism and making policy rather than applying the law--exactly what the Ninth Circuit said courts were not to do. To defend against this very notion, however, justice is supposed to be blind. Indeed, Lady Justice is depicted with a blindfold. To judge by selectively choosing which facts to emphasize is akin to lowering the blindfold and taking a peek, thereby rejecting equal justice under the law. Those who are called to judge must adhere to the rule of law no matter what they personally think the law should be or what the outcome of a particular case should be.

After she was nominated to the Supreme Court, Judge Sotomayor told the Judiciary Committee:

My personal and professional experiences help me listen and

understand, with the law always commanding the result in

every case.

So we are left to wonder what has caused this contradiction, and whether she still believes that judges may choose to see the facts they want to see to get the result they want to get.

Also, I indicated I had a concern about foreign law. Another very puzzling contradiction in Judge Sotomayor's testimony involves the issue of judges looking to foreign law when deciding cases.

In her testimony before the Judiciary Committee, Judge Sotomayor said:

I have actually agreed with Justices Scalia and Thomas on

the point that one has to be very cautious even in using

foreign law with respect to the things American law permits

you to.

However, in March of this year, in a speech to the ACLU of Puerto Rico, she did not seem to agree with Justices Scalia and Thomas when she said:

And that misunderstanding is unfortunately endorsed by some

of our Supreme Court justices. Both Justice Scalia and

Justice Thomas have written extensively criticizing the use

of foreign and international law . . . in Supreme Court

decisions. How can you ask a person to close their ears?

Ideas have no boundaries. Ideas are what set our creative

juices flowing. They permit us to think, and to suggest to

anyone that you can outlaw the use of foreign or

international law is a sentiment that's based on a

fundamental misunderstanding. What you would be asking

American judges to do is to close their minds to good ideas.

. . .Unless American courts are more open to discussing the

ideas raised by foreign cases, and by international cases, we

are going to lose influence in the world.

Mr. President, I do not agree. In fact, that a nominee to the highest Court in our land would say that our Constitution and our statutes in America may be interpreted by reliance on foreign law is alarming.

The Supreme Court is charged with deciding the constitutionality of a law or interpreting it in the context of our American system of justice, not in accordance with selectively chosen foreign laws, which are numerous, contradictory, and often inconsistent with American jurisprudence. How else would a judge choose among these various foreign laws and precedents other than selecting those that align with that judge's personal opinion?

Mr. President, I have raised three issues today that have caused me very significant concern: Judge Sotomayor's interpretation of the second amendment right to keep and bear arms, clearly written after the Supreme Court of the United States has given the guidance necessary for us to resolve the issue; her penchant toward choosing facts, enabling a judge or Justice, in this case, to reach the outcomes they want regardless of the way the law should be applied and the outcome that the law would otherwise require; and her willingness to allow American jurisprudence to be determined at the highest levels in our land by reliance on foreign law, foreign cases, and foreign precedent.

For these reasons, I cannot support President Obama's nomination of Judge Sotomayor to the Supreme Court. When we get to the vote on it this week, I will cast a ``no'' vote. I recognize the likelihood is her nomination will proceed and be confirmed, but it is my keen hope and conviction the issues I have raised and that many others have raised today will be heard and that, regardless of the outcome of the vote in the Senate this week, Judge Sotomayor, if she is confirmed, and all Justices on the Supreme Court will continue to recognize the fundamental nature of our right to bear arms under the second amendment; that they will focus on the proper role of judges not in creating law but in interpreting the law, and that they will decline to rely on foreign law to interpret and to create American jurisprudence.

With that, I yield the floor and note the absence of a quorum.

Mr. President, I rise today to speak in support of the Algae-based Renewable Fuel Promotion Act.

I would first like to thank Senator Bill Nelson for his leadership on this extraordinary piece of legislation, which gives algae-based biofuels the same tax incentives that cellulosic biofuels currently enjoy. Specifically, the bill would provide a $1.01 per gallon tax credit and offer 50 percent bonus depreciation for property used in the production of algae-based biofuels. In short, this legislation will level the playing field for algae, resulting in enhanced development and commercialization.

Recent technological advances have showcased the tremendous potential of algae as a renewable fuel source. Algae-based biofuels can be refined into gasoline, jet fuel and diesel. These fuels are renewable, have a low-carbon footprint, and can fit seamlessly into our existing energy infrastructure. Additionally, algae does not compete for arable land or potable water. Algae grows best in very sunny climates, making the desert an ideal place for production, and it utilizes saltwater, not freshwater, to grow. It also has a short-life cycle and high oil content.

Algae-based renewable fuels will play an important role in America's clean energy portfolio, and provide an answer to the question of how we will decrease our dependence on foreign oil and increase our domestic security. Again, I thank my colleague, Senator Bill Nelson, and I look forward to working with my colleagues in the Senate on this important piece of legislation.

Mr. President, I rise today to speak in support of the Algae-based Renewable Fuel Promotion Act.

I would first like to thank Senator Bill Nelson for his leadership on this extraordinary piece of legislation, which gives algae-based biofuels the same tax incentives that cellulosic biofuels currently enjoy. Specifically, the bill would provide a $1.01 per gallon tax credit and offer 50 percent bonus depreciation for property used in the production of algae-based biofuels. In short, this legislation will level the playing field for algae, resulting in enhanced development and commercialization.

Recent technological advances have showcased the tremendous potential of algae as a renewable fuel source. Algae-based biofuels can be refined into gasoline, jet fuel and diesel. These fuels are renewable, have a low-carbon footprint, and can fit seamlessly into our existing energy infrastructure. Additionally, algae does not compete for arable land or potable water. Algae grows best in very sunny climates, making the desert an ideal place for production, and it utilizes saltwater, not freshwater, to grow. It also has a short-life cycle and high oil content.

Algae-based renewable fuels will play an important role in America's clean energy portfolio, and provide an answer to the question of how we will decrease our dependence on foreign oil and increase our domestic security. Again, I thank my colleague, Senator Bill Nelson, and I look forward to working with my colleagues in the Senate on this important piece of legislation.