Floor Statements

Will the Senator yield for an observation?

I thank the Senator for yielding.

Madam President, I will be very brief. I thank the Senator from Tennessee, not only for his statement but for his constant efforts. Facts are stubborn things. Yet he has pointed out basically what this report now confirms. During the last few months we have seen some commentary that says ``scare tactics,'' of all things. I happen to have the privilege of being the chairman of the Rural Health Care Caucus. I was in the House of Representatives when I had the privilege of serving there and I am a cochairman with Senator Tom Harkin of Iowa. There are about 30 of us who, from time to time, will correspond and meet and send messages back and forth to try to keep the rural health care delivery system viable.

We have been worried for some time in regard to what is going to happen to Medicare, what is going to happen in regard to cost, what is going to happen in regard to rationing. Every hospital director, every hospital board in rural America has worried about these things--more especially about CMS, which has been described here in detail. That is the Centers for Medicare and Medicaid Services.

I have to tell you, if you are a hospital administrator or if you are on the board of a local hospital in a rural area, and you hear the word CMS, it is probably not viewed in the best of considerations, that CMS is in charge of enforcing what H2S comes down with. So in terms of reimbursement, in terms of all things--competitive bidding--and I am talking about doctors, hospitals, nursing homes, home health care, hospice, all of this--when they hear the word CMS a cold chill goes down the back of their neck, more or less like expecting Lizzy Borden to come in the front door.

So I am especially glad that the actuary, Mr. Richard Foster, the Chief Actuary from CMS, has shined the light of truth into darkness. He has taken the original bill we have been talking about for some time, as my colleague has pointed out, and said basically this bill is going to increase costs and is going to result in rationing. It does not take into consideration the latest iteration that we hear from the press and media about including people 55 to 65 into Medicare. It is going to be interesting, if we have enough time--although I know that the distinguished majority leader has asked for a CBO score--but I would sure like to know what Mr. Foster would think of that idea. I think it would be far worse.

I encourage all of my colleagues who belong to the Rural Health Care Caucus to take a very hard look at this. This confirms what we have been saying for some time. These are not scare tactics, these are actual facts.

Let me say, too, I know when this debate first started some of the national organizations that represent doctors and hospitals, perhaps nursing homes--certainly not any home health care--well, I take that back. There was a letter written by the home health care folks at one time, but certainly not hospices--indicating that they were lukewarm, warm to the bill, or would perhaps support it. I think the message was pretty clear--come to the breakfast or you won't come to lunch. That was pretty bare knuckles but they hoped that at least by insuring those who have insurance, that would make their situation better.

Then, of course, came the latest iteration to this bill of putting in people 55 to 65, and the national association, in regard to our doctors and our hospitals, said: Whoa.

Let me point out in Kansas and in many States throughout the country there never was the support. They knew exactly what would happen if we passed this bill and CMS would come knocking on their door. I might add it wouldn't be CMS that would actually do that, it would be the Internal Revenue Service under this bill, and that was one consideration where I made about a 15-minute speech and obviously not too many people paid attention. But all patients, all doctors, all nurses, all clinical lab folks, anybody connected with the home health care industry or hospice or nursing homes or whatever, should have known it is going to be the IRS that is going to enforce this as well as CMS, which has been doing most of the enforcing.

In Kansas, the Kansas Medical Society said: No, no, we are not going to go along with this bill. I am talking about the bill we have been talking about for some time. The Kansas Hospital Association was adamant. They said no. Obviously that was because of advice they got from 128 hospitals in my State, saying: No, we cannot reconcile with this because of cost, because of the rationing. We are only being reimbursed at 70 percent or less, as we talk about it--and the doctors about 80 percent.

Many doctors do not serve Medicare now in Kansas. Let me rephrase that. Some doctors don't serve Medicare in Kansas. If this bill passes, a lot of doctors simply will not serve Medicare. You can have the best plan or the best card in the world, it is not going to make any difference if you can't see a doctor. It is not worth a dime.

Then I have to say the Kansas Nursing Home Association and Kansas Home Health Care folks and the Kansas Hospice folks all said: No, this is not where we want to go. This is self-defeating. This is not going to do what the sponsors of the bill and what everybody for health care reform hoped they would actually see happen.

I don't know what the word is, I am--not overwhelmed, I am extremely glad; I am somewhat surprised but I am extremely glad that CMS again shined the light of truth into darkness. I commend Mr. Foster, the chief actuary. I recommend this as required reading for everybody who was going to vote for this bill and certainly with the latest iteration, where we are adding anywhere from 10 to 20 to 30 million people to Medicare, which will make the situation much worse in regard to Medicare being actuarially sound and costs going up, premiums going up, and also rationing, the dreaded rationing. It is not a scare tactic but actually a fact.

I yield my time.

I will tread with great care, I would say to my distinguished friend.

I thank the Senator for this colloquy. But you asked what it means that ``the Senate should reject any procedural maneuver that''--that is in quotes--and what does that really mean?

Well, it applies only to the Senate procedural motions. By itself it would have no effect on any substantive provision. That is the way it is commonly understood under Senate rules. It means, if adopted, the amendment would not remove any provision that has been identified as a tax increase on middle-class taxpayers, which is precisely what the Senator is trying to do. So basically it means nothing.

Will the Senator yield for a question?

That phrase that the Senator just mentioned is, ``which is designed to kill legislation.'' My question has already been answered by the distinguished Senator, what does it mean, but there are no motions that have been considered or pending, including the pending motion to commit by the distinguished Senator--is the motion designed to kill this legislation? Because that is what you are going to hear on the other side, and that is not the case.

Would the distinguished Senator yield for a question?

As Republicans, there is probably no principle that unifies us more than keeping taxes low on American workers and families, and I don't think our friends on the other side would dispute that notion. Indeed, the Democratic Party assumed control of the White House almost a year ago, as everybody knows, and seated large majorities here in the Congress. The one unmistakable distinction between the parties is this: Our party has respectfully opposed--I underline the word respectfully--opposed numerous efforts by the majority party to impose broad-based taxes increases on American workers and families. So one only need to look at the stimulus debate or the budget debate or the cap-and-trade legislation, and I could go on and on and on, more especially with the health care debate, and the bill before us.

Don't you follow from that general principle?

Would the Senator yield?

I wish to thank our distinguished leader for pointing that out. It has been a seminal event. As I said before, I have the privilege of being chairman of the Rural Health Care Caucus. There are probably 30 of us in a bipartisan caucus to try to protect and improve the rural health care delivery system. I took that report by Mr. Foster, who is the actuary of CMS, and said, this is required reading. I made the point that if you mention CMS to a beleaguered hospital administrator or a member of the board or any medical provider--doctor, nursing home, home health care, hospice; even hospice is cut in regard to the cuts--they know if a CMS representative is knocking on the door, that is a lot like sending a cold shiver down their spine thinking it is Lizzie Borden. Of all of the agencies that now are shining the light of truth into darkness in regard to the nature of this bill in increased costs, and yes, rationing--no, it is not a scare tactic--CMS is that agency. It would be amazing if we could get CMS to report back on, if we knew what it was--the media reports are how we get the information on this new iteration of a bill where allegedly we are going to add in people from 55 years old into the Medicare system. You do that, and now all of a sudden even the national organizations, let alone the State provider associations who have been opposed to this, to say, Whoa, we can't do that. That is going to break the system.

What I wish to point out and what I think is another piece of information that has sort of been overlooked, the CBO has estimated the cost to the Internal Revenue Service to implement taxes and penalties and enforce them--I am talking about the IRS now, not CMS, but the IRS that is going to implement and administer and enforce taxes and penalties on the bill--that cost is $10 billion estimated by CBO. That would double the budget size of the IRS. We have to train these people, and then you have to figure out what kind of questions they are going to ask of employers and employees in regard to the fines and the fees, you have to read the fine print. The American people understand this tremendous tax increase is going to be administered by the IRS and that is not going to be a happy circumstance. But those two things that the leader has brought out are absolutely primary in this debate.

I think a side-by-side is a straw man. I think it is very clear about that. I am

happy to comment on that further. I wish to give others an opportunity to speak.

Will the Senator yield for another question?

I would like to get back to the side-by-side amendment allegedly being offered by the chairman of the Finance Committee, the Senator from Montana. I said straw man, and that is pretty harsh, but I intend it to be. We have seen how, if the language is examined, the amendment, at a minimum, is a red herring. You can fairly say the amendment, rather, has no other purpose than to facilitate a strong argument.

On Tuesday, when Senator Crapo laid down his amendment, the majority didn't show us this side-by-side amendment until shortly before we thought--and they thought--we were going to vote. So that very limited notice makes you think it may be more likely to distract from or muddy the clear question the Senator from Idaho brought; that is, the motion to commit before the Senate. The motion was designed to be to be straightforward, and the Senator did that.

A vote for the motion is a vote to send the Reid amendment and underlying bill back to the Finance Committee. Under the motion, the Finance Committee would report back a bill that eliminates the tax increases on middle-income taxpayers. One could not say it anymore simply. That is what the motion does. The other bill is a straw man.

After the remarks by the distinguished leader, I would say this may be a seminal event. I think that is one of the key votes where the other side could start to realize this and start to finalize this without all the rhetoric and ideology and philosophical support for this bill, and they could start the road back, if you will, of doing it in a step-by-step, thoughtful way--doing it, meaning real health care reform.

I commend the Senator. Again, this side-by-side is a straw man. The Senator is clear in what he wants to do. Under the Senator's motion, the Finance Committee would report back a bill that eliminates the tax increases for middle-income taxpayers. We can restart the debate in a bipartisan way, where we can agree on many common goals. I thank the Senator.

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

Parliamentary inquiry, Mr. President.

I will try it again. I thought it was worked out.

I ask unanimous consent for the second time that the order for the quorum call be rescinded so I may be--

So I may proceed for 15 minutes.

Is this a bipartisan objection, I would ask the Presiding Officer?

The bill clerk continued with the call of the roll.

I thank the President. I rise today to talk about health care in general and the latest proposal to come out in the form of the so-called compromise, if there is no objection. I wish to talk about the latest proposal to come out from what some of us have determined is the majority leader's behind-closed-doors effort for the compromise on the government-run health insurance plan. I will admit very readily I do not know all of the details of this plan, although I hope to in the very near future. I think most of my friends across the aisle are in the same boat and we are all getting our information from the Post, the Times, and the rest of the catch-up media.

But this is the compromise, as I understand it: The majority leader will drop the government plan in exchange for two major policies: first, a national insurance plan run by nonprofit insurance companies and supervised by the Office of Personnel Management; and second, a massive expansion of Medicare to tens of millions of people age 55 and older.

Putting aside the first policy which, frankly, I don't understand how it could possibly work, I cannot believe anyone is seriously considering expanding Medicare as a compromise to the government-run or so-called public option. It doesn't take a genius to see that a huge expansion of Medicare is, as one single-payer advocate in the House dubbed it, ``the mother of all public plans,'' further quoting: ``An unvarnished and complete victory'' for advocates of single-payer health care and socialized medicine. That is a very strong quote, but that is the way it was.

In other words, this is not a compromise to the public option--it is worse. Maybe we need to remind ourselves why moving toward more government control of our health care system is such a bad idea. We need look no further than our current government-run insurance plans, Medicare and Medicaid, for examples. Government-run insurance plans currently control nearly half of the market. With the government's power, they have the ability to set payment levels for doctors and hospitals and home health care agencies and even hospices and all other health care providers, not based on the actual costs those providers incur when treating patients, but instead based on whatever arbitrary spending target the budget crunching bean counters determine the government can afford.

To paraphrase one observer: These types of global government budgets transform patients from sources of revenue over which providers compete to attract and serve, into sources of cost for the government to avoid, shunt off, and treat as cheaply as possible. That is not right. This has clearly been the result in the Medicare Program, often heralded as the best of all of the government's health care programs.

So to review: Medicare has been on an ever shrinking path toward bankruptcy for years. The latest reports

from the Medicare trustees say the hospital insurance trust fund will go broke within the next 8 years. The program has $38 trillion in unfunded liabilities. How has the government responded? By severely underpaying Medicare providers and denying Medicare patients' claims. Medicare only pays doctors around 80 percent of their costs, and hospitals even lower.

Privately insured Americans pay a hidden tax of nearly $90 billion a year to make up for these underpayments. But even that hasn't been enough to keep some providers in business and able to afford to accept Medicare patients. Medicaid is even worse. Medicare is also a huge denier of claims. I think many of my colleagues would be surprised to hear that Medicare denies claims more often than most private insurance companies. In fact, in 2008, Medicare had the highest percentage and the highest number of denied claims in the country. Think about that when you hear some Senators demonize private insurance companies for denying claims. Medicare is even worse.

This bill already exacerbates these Medicare problems by cutting almost $\1/2\ trillion from this already woefully underfunded program. Now we are considering adding even more people. This is a sinking ship with no lifeboats, and we are adding more folks to the deck.

By underpaying health care providers and denying claims, Medicare already rations health care. Expanding Medicare to tens of millions of new people as envisioned by this compromise we hear about will take government rationing to a whole new level. Because as the government takes over more of the health care system and becomes responsible for more of the increasing costs of that system, the only way it will be able to afford this commitment is to ration health care. As I have said countless times before, this bill gives the government all the tools it requires to ration care.

From Comparative Effectiveness Research, to the independent Medicare advisory board, to the new powers granted to the Centers for Medicare and Medicaid Services, CMS and the U.S. Preventive Services Task Force, this bill puts the rationing infrastructure into place. The U.S. Preventive Services Task Force's recent change to its guidelines pertaining to mammograms was a perfect illustration of how your health care will be rationed under this bill. For those who don't know, the task force recently reversed its longstanding advice that women should start getting regular mammograms to detect breast cancer at age 40.

Why is this important? Because under this bill, the recommendations of this task force will carry the weight of law for both government- run--i.e., Medicare--and private insurance. If the task force recommends a particular treatment or a particular set of patients, then Medicare and private insurers must cover it. If it doesn't, they don't.

What do you think will happen to treatments and tests that don't get the task force's recommendation? They simply will not be covered. That is how the government will hold down health care costs, by rationing access to treatments and tests such as mammograms.

Some government-controlled health care systems such as the one that exists in the United Kingdom are much more explicit about rationing. The rationing in this bill, quite frankly, is not as honest. Since Americans would never stand for the government explicitly rationing their health care, the authors of this bill had to come up with a pseudoscientific justification for rationing, and that justification is the main feature of this bill: Comparative Effectiveness Research, or

Mr. President, I agree with the Senator. I point out that in the specifics of the bill, I think it says shall not, in regard to cost containment on Medicare A and B, but the rest is encouraged. That is where we get into problems because CER is the blueprint on how we allot health care dollars in this country.

I might mention to the Senator, I had a chart on what CER recommended, and it had a figure of a humpback whale and how much money we would be devoting to different age groups. If you are 60--and, by the way, the average age of the Senate is 62--you are out of luck. If you are 70, you better get something fixed real quickly before this bill passes. That is my point. I thank the Senator for his comments.

Madam President, I understand I am recognized for 15 minutes; is that correct?

Madam President, I understand the distinguished Senator from Michigan wishes to attend the very important Democratic conference on a brand new health care bill. I understand that, and I shall try to expedite my remarks, only with the suggestion to the Presiding Officer that when you are late in the Senate, you are early, and they are not going to say anything important without you.

I wish to yield at this time to the distinguished Senator from Georgia, who I understand has a statement to make.

Madam President, President Obama has repeatedly made two pledgees to the American people--and we have heard it and heard it before, and we will probably hear it again--about health care reform. The first is, if you like the health care you have, you can keep it.

We know the bill before us breaks this pledge because all but two in the majority voted to preserve the nearly $500 billion in cuts to Medicare, which includes $120 billion in cuts to Medicare Advantage.

The nonpartisan Congressional Budget Office, or CBO, has confirmed that these cuts to Medicare Advantage mean that ``approximately half'' of the Medicare Advantage benefits will be cut for the nearly 11 million seniors who are enrolled in this program.

This vote confirms whether Americans will be able to preserve and keep the health care benefits they have and like. That answer, unfortunately, is no.

So now let's look at the President's second pledge: that he will not raise taxes on families earning under $250,000 or individuals earning under $200,000.

A number of my colleagues have pointed to comments made last year in Dover, NH, by then-Candidate Obama, who said:

I can make a firm pledge--

And we have heard this before--

. . . 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.

I think he said ``by one dime'' at the end of that.

Yet time and again in this bill, that pledge is also broken. This bill calls for nearly $500 billion in new taxes, penalties, and fees that hit virtually every American, including middle-class families making less than $250,000 and individuals earning less than $200,000.

Even though the majority has tried to disguise these taxes as various ``fees'' and presents them as being paid for by targeted health care industries, the reality is that this bill taxes the average American coming and going.

It taxes you if you have health insurance. It taxes you if you do not have health insurance. It taxes you if you use medical devices, such as a hearing aid or a pacemaker. It taxes you if you save on your own to pay for your health care expenses. And it effectively increases taxes for individuals and families with catastrophic medical expenses.

Americans should understand that the higher taxes called for in this bill will come straight out of their pockets, with the middle class bearing much of this tax burden.

Let me give you a few examples of the new taxes proposed and who will pay for them.

The bill imposes a 40-percent excise tax on health insurance providers that offer high-cost health insurance plans. This provision is the largest tax hike in the bill and raises almost $150 billion and will be paid for primarily by individuals--not the health insurance provider, but by individuals--through increased income and payroll taxes.

By the time this bill is fully implemented, 84 percent of this tax on ``high-cost plans'' will be paid by Americans who earn less than $200,000--taxpayers the President promised would not pay additional taxes.

Second, the bill imposes new taxes on health insurance providers and medical device manufacturers. Both the nonpartisan Congressional Budget Office and Joint Committee on Taxation have said these taxes will be passed on to consumers in the form of higher insurance premiums. The new $60 billion tax on health insurance providers alone could raise premiums by as much as 2 percent according to some analyses, and that increase could come as early as next year.

Not only that, the $19.3 billion in new taxes on medical devices could increase costs for up to 80,000 medical products, such as heart stents, blood pressure monitors, eyeglasses, pacemakers, hearing aids, and advanced diagnostic equipment. Such a tax would stifle and will stifle innovation and reduce the ability for manufacturers to develop new lifesaving devices and technologies.

So make no mistake, the cost of this tax will be passed on to and paid for by anyone who uses a medical device, including those middle- class taxpayers the President has pledged will not experience any tax increase.

If you need a pacemaker or a stent, you will pay more for it because of these new taxes. If you need a diagnostic procedure, you will pay more for it because of this new tax.

Furthermore, under this bill, the floor for deducting medical expenses from income tax is raised from 7.5 percent to 10 percent of adjusted gross income. Those who will take this deduction are most often seniors and those with serious or catastrophic medical issues.

For a family of four, earning $57,000 in 2013, limiting the deduction means they would lose a tax deduction of $1,425. A family of four earning $92,000 would lose a tax deduction of $2,300.

It goes without saying, I think, that losing a portion of your tax deduction means you pay more in taxes. These are real dollars to hard- working Americans. This provision alone raises $15 billion in new taxes on Americans who deduct medical expenses.

Finally, this bill raises taxes for the more than 35 million Americans who participate in flexible spending accounts, or FSAs. For the first time, this benefit to middle-income workers is taxed to pay for new government spending and an expansion of entitlement programs.

FSAs are a key benefit for many families for whom health insurance does not cover or does not cover sufficiently some of their highest cost health care expenses such as dental, vision, as well as prescription drug costs. They are also important for individuals who manage chronic diseases such as diabetes, heart disease, or cancer.

Flexible savings accounts allow the participants to set aside money out of their own pocket to pay for these necessary expenses. However, under this bill, the government caps how much can be set aside in an FSA account at $2,500, effectively raising the tax burden on certain FSA participants and increasing their health care costs.

The typical worker who contributes more that $2,500 to their FSA has a serious medical condition. This means that under this bill, workers with serious illnesses and earning an average of $55,000 will be paying more in taxes.

I have highlighted a few of the many tax hikes in this bill and the fact that the middle-class taxpayers will bear the brunt of these higher taxes, but if there are any doubts remaining about what this bill means for Americans' pocketbooks, let's consider this. An analysis by the nonpartisan Joint Committee on Taxation looked at four tax provisions in the bill and how, when taken together, they will affect Americans. They looked at the tax credit for health insurance, the additional Medicare payroll tax, and several I have already mentioned, including the high-cost plan tax and the medical expense deduction limit. Their analysis shows that when this bill is in full effect, on average individuals making over $50,000

and families making over $75,000 would see their taxes go up under this bill. Even after taking into account the premium tax credit, the subsidy that the government will provide to help people offset the cost of health insurance, when this bill is fully in effect, more than 42 million individuals and families or 25 percent--one-quarter of all tax returns under $200,000--will see on average their taxes go up as a result of this bill.

In addition, based on the same information, the Joint Committee on Taxation identified two groups of taxpayers. The first are those individuals and families who are not eligible to receive the premium tax credit to purchase health care, and second are those individuals and families whose taxes will increase first before they then see some type of tax reduction as a result of their premium tax credit. Taking these two groups together, the number is even more disturbing: 73 million individuals and families or 43 percent of all tax returns under $200,000 will on average see their taxes increase under this bill, says the Joint Committee on Taxation.

To put it another way, under this bill, for every one individual or family that benefits from the tax credit to purchase insurance, this bill raises taxes on three middle-income individuals and families. These tax increases are on top of those I discussed earlier, such as the new taxes on FSAs, so the estimates I have already mentioned understate the tax impact, again, on middle-income taxpayers. The JCT the Joint Committee on Taxation--has confirmed that these additional taxes, such as the FSA tax, will likely further raise the taxes of middle-income Americans.

All Americans, and middle-class taxpayers especially, need to take notice of what these higher taxes will mean for them and their families. They need to know these taxes will be used in part to pay for a vast expansion of the role of government in health care and more government intrusion into families health care choices.

Paying for health care on the backs of the middle-class and working Americans is the wrong solution for health care, violates the President's pledge to these taxpayers, and is terribly counterproductive in regard to the No. 1 issue facing this country, and that is jobs and the economy.

I urge my colleagues--I plead with my colleagues--to support the Crapo motion to prevent the enormous tax hike this bill inflicts on middle-class Americans.

Mr. President, I appreciate your indulgence. I know you are ready to go to your conference.

I yield the floor.

The PRESIDING OFFICER (Mr. Nelson of Florida.) The majority leader is recognized.

There is no ``forth.''

There is no ``forth,'' Mr. Chairman.

We could go back and back, sir--I do not care--and then forth and forth.

Madam President, I rise today in support of the motion of my good friend from Nebraska, my colleague from Nebraska, Senator Johanns to--the official words say: to commit the bill back to the Senate Finance Committee with instructions to strike the cuts to the Medicare home health care benefit.

What the distinguished Senator is trying to do is bring some common sense to the cuts to a very vital source of health care, not only to rural areas but all over this country, and that is home health care. The bill we are considering, the bill sometimes called the

``behind closed doors'' bill, would cut home health care by $42 billion.

The Senator from Nebraska says that is a head-scratcher, and it certainly is. It is more than a head scratcher; it is a Lizzie Borden amputation in regard to a vital program.

Home health care is critical for our seniors. Obviously, that is the truth. As the cochair of the Senate Rural Health Care Caucus, I certainly understand that. So does the Senator from Nebraska. He was saying yesterday how many times he visits his rural hospitals, rural clinics, rural hospices, and you do that a lot if you are from Nebraska or Iowa or Texas or Kansas.

At any rate, in my home State of Kansas and other rural areas, many seniors live alone or out in the country miles away from a local hospital or a doctor's office. Even if they have a very good doctor, they can't get there because of their health condition. So home health care allows those seniors the freedom and the independence to stay in their home in the comfort of knowing somebody is there assisting their health care needs. More importantly, home health care is the cost- effective care, as the Senator from Nebraska has pointed out, that keeps the senior out of a nursing home or hospital and--guess what-- saves the government money. Over the long term, if you cut home health care, you are going to increase the cost in regard to nursing homes, no question about it.

In my State I have had the pleasure of being able to see firsthand, as has the Senator from Nebraska, the great work our Kansas Home Health Care Association members do every day. Last year I was invited into the home of a lovely couple in Concordia, KS, America, not too far from Nebraska, and despite having multiple health issues, Duane and Phyllis were able to stay in their home with their little dog Josie, all thanks to the services provided by a home health care aide and a home nurse.

What is going to happen to seniors such as Duane and Phyllis if we slash $42 billion from home health care payments? Forty-two billion dollars is one of the largest Medicare cuts in the whole bill next to Medicare Advantage and the hospitals. The Senator from Nebraska had that chart showing serious cuts to all of our providers. Don't forget that this cut comes on the heels of several years of additional cuts to home health care--around $35 billion all told--that already have a large percentage of Kansas home health care agencies operating at very slim or negative Medicare margins. I know the same is true in Iowa, and the same is true in Texas, in Montana, in Nebraska, and all over the country.

I keep hearing my colleagues, however, on the other side of the aisle insisting that their $\1/2\ trillion cut to all Medicare--here is the quote--``won't affect the benefits guaranteed to seniors.'' Please stop that. Please stop that. That is the most disingenuous smokescreen in this whole debate. It may be true that this bill does not explicitly cut benefits. My friends across the aisle, however, cannot deny that their cuts in reimbursements to providers will affect those benefits, because when you cut the reimbursements to providers, guess who pays the price. The patients--Duane and Phyllis and their little dog Josie. I tell you what. You come to their house and you make that argument that if you close down or make cuts to home health care, Duane is not going to like it, Phyllis is not going to like it, and Josie will bite you on your leg.

As I said, many of my Kansas home health care agencies are already operating at negative margins. Their projected share of these cuts, as provided by the distinguished Senator from Nebraska, is almost $240 million. To the Senator from Montana, the distinguished chairman of the Finance Committee, my dear friend, that is $60 million in Montana; and Nevada, where the distinguished majority leader lives, the chart that has been provided to me by the Senator, $263 million.

We have Senator Cornyn sitting right behind me here. Senator Cornyn, you are in the $6.8 billion category for Texas. I might ask the Senator, What is going to happen if you get cut $6.8 billion in regard to home health care service?

I thank the Senator. The Senator from Nebraska has already pointed out what happens in Nebraska, and I know what will happen in Kansas. Nearly two-thirds of Kansas home health care agencies will have negative margins within only 5 years, probably 2 or 3, if these cuts are allowed to occur.

How are these agencies supposed to stay in business with these kinds of cuts? The home health care benefit will be worthless to a Kansas Medicare patient whose home health care agencies will go out of business. So, yes, in fact, this bill will effectively cut benefits. Again, get rid of the smokescreen.

This doesn't apply just to the home health care benefit. The same can be said for the effect of the cuts, as demonstrated by the Senator from Nebraska, for reimbursements to hospitals. This bill is going to cost the Kansas Hospital Association $1.5 billion. They have some outside experts who came in. I asked them: What is going to be the effect of the cuts? They already have cuts. They only get reimbursed 70 percent now, and $1.5 billion on top of that. We ought to have a chart--and I am sure we will have a chart--that would show Iowa or Nebraska or any State here, Texas especially, because of the number of folks there. So hospitals, hospices, skilled nursing facilities, and all of the rest.

I want every senior to know that while maybe it is technically accurate, again, for my friends across the aisle to claim this bill doesn't cut Medicare benefits, there is no way--no way--you can slash $\1/2\ trillion from payments to providers without affecting their ability to keep their door open, especially in rural and small town America. Seniors should know they will be left with a worthless benefit. To paraphrase my friend Senator Alexander from Tennessee, it would be like having a bus ticket without a bus.

Thank you, Senator Johanns. Thank you for the work you are doing. Thank you for this motion. I hope we are successful. I hope people will wake up and understand the severity of what these cuts will do. I urge every Member of this Senate to support Senator Johanns when we come to a vote on this issue.

Thank you, Mr. President. I yield the floor.

Mr. President, I thank the distinguished Senator from Montana and my chairman of the Finance Committee.

Let me say first to the Senators from Washington State that I think all Senators appreciate both Senators bringing to the attention of the Senate the heartfelt feelings in regard to the tragedy that happened in their State. I share their dismay with regard to what has happened. I know the thoughts and prayers of all Senators are with them. I appreciate the remarks they have brought to the body at this time.

I would now like to discuss briefly the motion to commit in regard to Medicare and the tremendous cuts that are proposed in the bill--a bill I define not as the Finance Committee bill, not as the HELP Committee bill, but the bill that was done behind closed doors, which I think was most unfortunate.

This bill slashes--and I think that is the appropriate word--nearly $\1/2\ trillion from Medicare. Then it is used to establish a huge new government entitlement program.

Earlier this year during the Finance Committee markup of the health care reform legislation, I offered a nearly identical amendment to the McCain motion to commit we are now considering, which is a motion simply to send the legislation back to the Finance Committee with instructions to strike the cuts to Medicare in this bill. Unfortunately, my amendment during that time failed in committee on a party-line vote.

Let me see if I understand this correctly. Medicare is going broke. It has around $38 trillion in projected future unfunded liabilities. It is a huge, crushing entitlement program that threatens to bankrupt this country. But instead of owning up to this enormous threat and doing something about it for our financial future, instead of considering a Medicare reform bill to address this menace to future generations of Americans, instead of guaranteeing that the government-run plan we currently have remains solvent, instead we are actually cutting some $465 billion from Medicare in order to start a brandnew, huge, crushing entitlement program that makes no sense.

If Medicare needs to be reformed--and I certainly believe it does-- then we should be considering a Medicare reform bill right now. We certainly should not be cutting Medicare for the purpose of financing a huge new entitlement program.

My friends on the other side of the aisle have the temerity--that is a pretty strong word, but I think it applies--to assert these huge cuts will actually make Medicare more solvent. Nothing could be further from the truth. I have news for them. Cutting reimbursements to doctors, cutting reimbursements to hospitals and other providers--all providers--and it has been mentioned by my distinguished colleague from Nebraska--home health care providers, hospices is not reform. These cuts will hurt Medicare beneficiaries, our seniors who have worked their entire lives with the promise that this program would support them through their older age.

Medicare already pays doctors and hospitals well below cost--70 percent approximately for hospitals, 80 percent for doctors approximately. The only saving grace is that these providers have the ability to shift their losses on to private payers to keep their doors open or their practices going. But there is a limit to their ability to cost shift. There is only so much the private sector is willing to absorb.

American families already pay--now get this--an extra $90 billion in a hidden tax to make up the Medicare and Medicaid underpayments that we in past years have provided each year. More cuts to reimbursements coupled with the massive increase to Medicaid this bill assumes will push these limits, meaning that fewer doctors will open their doors to new Medicare patients. They are doing that right now. We are rationing right now as to access to doctors who accept Medicare patients, and health care access and quality for our seniors will be compromised.

Take the $105.5 billion cut to hospitals as an example. I know the National Hospital Organization has signed off on these cuts. I don't know why, but they have signed off on these cuts. I also know for a fact they will harm Kansas hospitals. I asked my Kansas Hospital Association--I did, at my request--to run the numbers on how this bill will affect their bottom lines. Their findings are frightening.

According to the Kansas Hospital Association's outside experts, this bill will result in nearly $1.5 billion in losses to Kansas hospitals over the next 10 years. It may be true that some urban hospitals that currently have large percentages of uninsured patients may have some of their cuts offset by the potential reduction this bill will make to the uninsured population. But that is no consolation to a hospital in McPherson, KS, for example, that may be too large to qualify for the higher reimbursements allotted for what we call critical access hospitals, and has, unfortunately, the misfortune of serving a smaller than average uninsured base. Those hospitals will see huge cuts without seeing any of the gains. This bill's $100 billion cut will only hurt these hospitals and their ability to serve Medicare and even non- Medicare patients. Remember the cost sharing.

Medicare's own actuaries at CMS, the Center for Medical Services-- sort of an oxymoron--have agreed that the Democrats' cuts to hospitals and other providers could be dangerous and could cause them to end their participation in Medicare. So why are we doing this?

Another huge cut to Medicare in this bill is that $120 billion cut to the Medicare Advantage Program. My distinguished colleague from Nebraska has already talked about that, the effects of Medicare Advantage to Nebraska. Let me talk about Kansas. Close to 11 million, or one-quarter, of Medicare beneficiaries are enrolled in Medicare Advantage; 40,000 of those beneficiaries are in Kansas. I want to read an excerpt from one letter I received from a very satisfied Medicare Advantage customer in Shawnee, KS. Ms. Lila J. Collette is enrolled in Humana Gold Plus, a Medicare Advantage plan. She writes:

Please use everything in your power to let me and the many,

many other people in Kansas who have chosen Humana Gold Plus

to keep this wonderful plan.

Ms. Collette is not alone. Satisfaction rates among seniors enrolled in Medicare Advantage plans are very high. I know they are very unpopular to the other side and there are a lot of allegations made, but these people made that decision on their own, so why are we essentially gutting this program that provides quality and choice to our seniors?

I could go on about the cuts to hospice, home health care providers, nursing homes, but I think you get the point. I disagree with the failure to prioritize the solvency of Medicare over the establishment, again, of new government programs. And I certainly will never agree to financing these government expansions by bleeding the Medicare Program dry.

That is why, as I have said, I offered amendments in the Finance Committee markup that would have struck these Medicare cuts. Again, unfortunately, they were defeated on a party-line vote.

As the President is fond of saying, ``Let me be clear.'' This bill is funded on the backs of our seniors and those who provide Medicare to our seniors. This bill slashes Medicare by $\1/2\ trillion. This bill threatens access to care for seniors and health care for all Americans. I hope my colleagues will join me in opposing these cuts by voting for the McCain motion to commit.

This is the key vote. Don't kid yourselves, this is the key vote. You are either for protecting Medicare or not.

I yield the floor.

Mr. President, I ask unanimous consent that my staff member, Mr. Brett King, be granted the privileges of the floor.

Mr. President, I ask unanimous consent that I be permitted to engage in a colloquy with my Republican colleagues.

Mr. President, this is the health care bill. There are a lot of things in this bill that I object to. The $2.5 trillion cost, the 24 million people still left uninsured, the unconscionable $\1/2\ trillion cuts to Medicare and our senior citizens, with another $\1/2\ trillion in job-killing tax increases, in my view, the stunning assaults on liberty, and the Orwellian policies making health insurance even more expensive--any one of these things would make me vote no on this bill. But one issue has me troubled the most; that is, the issue of rationing. We have several of my colleagues here who will speak to this subject, and we will engage in a colloquy. I don't think this issue has sunk in with the American people and, for that matter, the media.

I want everyone to understand something. This bill aims to control the government's spending by rationing your access to health care. Let me repeat that. This bill aims to control the government's spending by rationing your access to health care. There are at least four government entities--we decided to call them ``the rationers''--that will stand between you and your doctor, and these four entities are represented by the four walls on this chart behind me blocking the doctor-patient relationship. You can see a pair of senior citizens and with frowns on their faces and then we have the rationers. We have an institute, a board, a center, and a task force, some of which are in place now and some are not. But every Senator should know about them and every health care recipient or especially senior citizen should know about them. Senator Reid's bill establishes the Patient-Centered Outcomes Research Institute--that is the first wall--to conduct something called comparative effectiveness research, or CER, which is research that compares two or more of the same treatment options for the same condition to see which one works best. That sounds like a good idea. But, unfortunately, when CER is conducted by a government under pressure to meet a budget, it can be manipulated in some very sinister and counterproductive ways, as has been demonstrated by the United Kingdom's CER Institute. They call theirs the National Institute for Health and Clinical Excellence. The acronym is NICE, but NICE is not very nice in Great Britain.

NICE is notorious for delaying or outright denying access to health care treatments based on CER that takes into account the cost of the treatment and the government's appraisal of the worth of the patient's life or comfort. Some of the more shocking CER decisions handed down by NICE over the years include: restricting access to drugs to save seniors' vision from macular degeneration until the patient is blind in one eye, inconceivable; denying access to breakthrough treatments for aggressive brain tumors; and refusing to allow Alzheimer's therapy until the patient deteriorates.

The Patient-Centered Outcomes Research Institute will be the American version of NICE using CER to save the government money by rationing your health care.

Over the past few months, I have offered several amendments, along with Senators Kyl, Coburn, and Enzi, to protect American patients from NICE-style rationing, to prohibit this bill from valuing cost containment over the care of patients. Unfortunately, they have all been voted down on party-line votes in the HELP Committee, the Finance Committee, and previously on the floor.

Let's move to the independent Medicare advisory board. That is the second wall between patients and their doctor. The Obama-Reid bill establishes a new independent Medicare advisory board, an unelected body of 15 experts who

will decide Medicare payment policy behind closed doors with minimal congressional input--something that is happening all too often around here. Although the bill says this anonymous board shall not include any recommendation to ration health care, what else would you call denying coverage for Medicare patients based on cost? That is what this board will do--deny payment for knee replacements or heart surgery or breakthrough drugs, all to achieve an arbitrary government spending target. I don't know what you call that, but I call it rationing. Also notice that this board will necessarily ration access to health care based on age and disability. Its payment policies will only affect the elderly and disabled who receive Medicare.

What will be a patient's recourse if Medicare refuses to pay for an innovative new therapy that could save or prolong their life? These are the reasons why the Wall Street Journal has dubbed this board the rationing commission.

Let us move now to the CMS innovation center. We come to the third wall between the doctor and patients. The Centers for Medicare and Medicaid Services, or CMS--and every provider knows what that is-- administers the Medicare Program upon which 43 million Americans rely. That is almost 15 percent of the population. CMS already rations care. This has already been referred to by Senator Thune and others in their comments on the floor. It is not authorized to but it does so indirectly through payment policies that curtail the use of virtual colonoscopies, certain wound-healing devices, and asthma drugs. In fact, courts recently had to intervene to prevent CMS from rationing a relatively expensive asthma drug in Medicare because rationing is currently against the law.

However, the Reid bill establishes a new CMS innovation center which will, for the first time, grant CMS broad authority to decide which treatments to ration.

Let's go now to the U.S. Preventive Services Task Force. That is the last one right here. The U.S. Preventive Services Task Force is yet another panel of appointed experts--a lot of those in this bill--who make recommendations on what preventive services patients should receive.

Currently, the task force recommendations are optional, but the Reid bill bequeaths this unelected and unaccountable body with new powers to determine insurance benefit requirements in Medicare, Medicaid, and even in the private market.

The task force has already revealed the types of recommendations it will be making. Just last week it decided to reverse its longstanding recommendation that women get regular, routine mammograms to detect breast cancer starting at age 40. One has to wonder if the task force's abrupt about face has anything to do with the fact that the Federal Government's financial responsibility for these screenings and for the health care needs they could potentially reveal will be greatly expanded if this health care reform bill passes.

In the words of one prominent Harvard professor:

Tens of thousands of lives are being saved by this

screening, and these idiots want to do away with it. It's

crazy. It's unethical, really.

The outcry from oncologists, the American Cancer Society, the American College of Radiology and breast cancer survivors and families across the country has forced our Health and Human Services Secretary, Kathleen Sebelius, to backpedal away from the task force recommendation, saying they do not affect government policy. As a matter of fact, Secretary Sebelius said: Let you and your doctor make the decision. But this bill relies on the task force's recommendation, some 14 times throughout the legislation, to set benefits and determine copayments and make grant awards. So contrary to the Secretary's assertion, if this bill passes, the recommendation of the task force will become government policy. Not only that, it will be forced onto private insurers as well.

Some may ask, after my comments: Why so cynical? Why not trust these tools that they will only be used for good, to advance medical science and patient care. I hope that is the case. To those folks I answer by showing this chart over here by Dr. Ezekial Emmanuel and his ``complete lives system.'' As many of you know, Dr. Emmanuel is the brother of White House Chief of Staff Rahm Emmanuel. He is a bioethicist, one of those special advisers to the President. Perhaps he could actually be the rationing czar.

Dr. Emmanuel has published very disturbing ideas on how to ration care, which could be summed up by this ``Brave New World'' humpback whale graph we have here, along with aging groups of the population.

Dr. Emmanuel's Complete Lives System--something that sounds a little bit like a cure-all elixir sold out of Del Rio, TX--basically works off the premise that the older you are, the more you have lived and, therefore, the less you deserve in terms of health care.

I would like to point out that the average age of a Senator is 62-- just something for all of you to think about, as you look at this chart depicting the Complete Lives System.

As shown on this chart, if you are 10 years old, you are doing pretty good right here. Twenty years old, that is when you think you are bulletproof and you do not want insurance, but you have a lock under this plan. Thirty years old, you are in pretty good shape. Forty, here comes the roller coaster. Fifty, you are in trouble. Sixty, you might as well forget it. Seventy, well, you are off the chart.

President Obama has clearly listened to Dr. Emmanuel's counsel. Remember his observation in an interview this summer that, as patients get closer to the end of their life: ``Maybe you're better off not having the surgery, but taking the shots and the painkiller'' instead.

Well, as someone who falls toward the end of Dr. Emmanuel's bell curve here--as shown over here on this chart--this type of thinking is unbelievable: Telling someone they cannot have a knee replacement because they are too old? How old is too old, according to Dr. Emmanuel?

The Wall Street Journal reported on the age rationing that occurs in Canada. In that country, apparently 57 is too old for hip surgery. Perhaps they can drive south and find care right here in the United States. But I am not sure where they will go if this bill passes.

The White House may complain that I am taking Dr. Emmanuel's musings out of context. My response to that is this: This is the context right here. This is how the government will contain costs. All these policies must be viewed through the prism of these ideas: This institute, this board, this center, this task force follows that blueprint. This is the goal: to save the government money by rationing care, by basing that rationing on some pseudoscientific graph such as this. At least in the United Kingdom they are honest about it.

These are the tools of rationing. These tools will restrict your ability, and your family's ability, to get a knee replacement or a breakthrough cancer drug or treatment for Alzheimer's or a mammogram.

They will destroy the American health care system--the best health care system in the world. And they are the main reason why I will vote no on this bill.

I yield to Senator Snowe.

Madam President, it is my understanding that I am going to be recognized for approximately 15 minutes, and I seek unanimous consent that Senator Grassley follow me for 15 minutes, so we would take approximately 30 minutes of the Senate's time at this point. I think I should probably ask unanimous consent to proceed as in morning business.

Madam President, I come to the floor today to join my good friend from Iowa, Senator Grassley, who is our ranking member on the Senate Finance Committee, to raise concerns about a too-little- discussed aspect of the health care bill the Senate will soon debate. While much of the health reform debate to date has focused on the health care side of the bill and the $500 billion in higher taxes, fees, and fines that will be required to pay for it, very little attention has been paid to how these taxes and fines will be implemented and administered and, most importantly, enforced. I think that is a very critical discussion. We need to have that discussion, and it is one the American people fully need to understand as this debate gets underway. This is important stuff.

Senator Grassley has already sounded the alarm about how the Senate Finance Committee bill expands the size and reach of the Internal Revenue Service, the IRS, further into the lives of every American. But listen up: All the health care bills we have seen so far call for reforms to be carried out to a great extent by the Internal Revenue Service--that is right, the IRS, the Nation's tax collector.

This isn't CMS, the Department of Health and Human Services; this is the IRS. So the Nation's tax collector will be in charge of implementing, administering, and enforcing a significant portion of this bill.

Under the various bills, the IRS is given unprecedented authority to obtain information about your family's health care decisions. The IRS is authorized to collect new information--information that is unrelated to an individual or a family's tax liability--in order to carry out health care reform.

This information will be used to implement, administer, and enforce several controversial provisions. For example, the IRS--again, not the Department of Health and Human Services--is the government agency that will determine whether everyone has insurance and will assess a tax penalty on anyone without insurance. The IRS will have to collect additional information from individuals and families in order to make this determination. We don't know how this information will be collected or how it may be used.

The IRS would assess taxes on employers who do not provide affordable coverage for their employees. Since affordability would be determined on an individual's total income, an employer would have to collect income information from all of his or her employees. This will require employers to provide additional information about their employees to the IRS--information I am sure that an employer would just as soon not ask about. We don't know how an employer would use this information or how it would be protected.

In addition, the IRS will have to work with the new health care exchanges to verify whether an individual is eligible for a subsidy and will have to share information about taxpayers with those exchanges. However, we still don't know if the exchange will be a State agency or a private entity, so we don't know how the IRS will collect and safeguard taxpayer information.

Yet even as the health care bill creates new responsibilities for the IRS, consider that the IRS is having a lot of trouble doing its No. 1 job--tax administration--efficiently and effectively. Two reports were issued recently that I think raise questions about the IRS's ability to carry out its new responsibilities in this bill, let alone its original responsibilities.

Last week, the Government Accountability Office, or GAO, released its annual audit of the IRS's financial statements for 2008 and 2009.

In the report, the GAO found that while the IRS has made progress in addressing internal control deficiencies, the report also states that deficiencies remain with regard to the IRS's internal control over unpaid tax assessments and over information security. The report states that ``the serious challenges IRS faces as a result of these remaining deficiencies adversely affect the IRS's ability to . . . obtain current, complete, and accurate information it needs to make well- informed decisions.''

Then, on Monday, the Treasury Inspector General for Tax Administration found that because of the way the Making Work Pay credit--the credit created in this year's stimulus bill to provide workers with a one-time tax credit of up to $400--has been implemented and administered by the IRS, more than 15 million taxpayers may actually end up having to pay back some of their credit to the IRS.

Similar administrative problems with the home buyer tax credit have led to waste and abuse of taxpayer dollars.

The IG's audit of the IRS's administration of the credit found that the IRS may have allowed thousands of taxpayers to claim millions of dollars in credits to which they were not entitled to despite recommendations made a year ago by the IG that the IRS take steps to verify eligibility for the credit.

In its audit, the inspector general found that more than 19,000 taxpayers claimed $139.4 million in credits for homes they had not yet purchased but would allegedly purchase. In addition, over 70,000 taxpayers claimed more than $479 million in credits despite indications that they were not first-time home buyers. The IG also identified 582

taxpayers under 18 years of age who claimed almost $4 million worth of credits. By the way, the youngest taxpayers receiving the credit were 4 years old.

Mr. President, the problems the IRS has encountered in administering these credits and the issues raised by the GAO about the security of taxpayer information--I will repeat that: the security of taxpayer information, your taxes--raise serious questions about whether the IRS is up to the task of implementing and enforcing the far-reaching tax proposals that are called for in the health care bill.

Wait, there is more. We know the IRS will need additional funding and employees--employees with expertise and training--if they are to implement, administer, and enforce the dozen or so new tax provisions called for in the health care bill.

How much will that cost? That is a good question. Nobody knows. These costs are not included in estimates provided by either the Congressional Budget Office or the Joint Committee on Taxation.

The bill as passed by the Senate Finance Committee--I don't know what is in the bill that will be considered, just announced by my friends across the aisle. They are doing that behind closed doors. But the bill as passed by the Finance Committee doesn't include any funding for the IRS for any administrative or personnel costs associated with this bill. We will see if the leader's bill that will be announced sometime tomorrow, which is being talked about in the hallways, contains such estimates.

Estimates of a more narrow bill by an independent group found that the IRS administration alone would cost several billion dollars--never mind the costs for the Department of Health and Human Services or CMS or other new Federal offices that will be created. We can only assume the cost to administer and enforce the taxes, fees, and fines in this bill will be significantly higher.

Americans need to understand what health care reform means for their health care, but they also need to know what the IRS's significant and intrusive new role would be in implementing and enforcing such health care reform.

All the proposals we have seen so far expand the reach of the IRS even further into the lives of ordinary Americans, allowing them to collect more information than ever before about you and your health care choices in order to tax you based on those choices.

Do Americans want the IRS to collect even more information about them and their families than it already does? I don't think so. Do they want the IRS having access to information about their health care decisions? Again, I doubt it.

Furthermore, would the IRS be able to do the job? Will they get it right? Recent reports by the IRS's own IG and the GAO cast doubt on the agency's ability to effectively administer the wide-reaching provisions in the health care bill.

Americans should be very concerned about putting the IRS in charge of administering more than $500 billion in new taxes, fees, and fines in this bill and expanding its reach further into Americans' lives.

Americans should be concerned about this path that the Senate leadership and the White House is taking us down, placing this very complex health care bill in the hands of the IRS, especially when they have not provided the resources the IRS will need to get the job done-- not to the funding.

Madam President, the bottom line is that Americans need to know, need to understand, and need to question whether they want the Internal Revenue Service more involved in their daily lives and their health care decisions. Under the proposals we have seen, that is the case.

Sit up, America, and take notice. I think if we took a poll or had yet another townhall meeting, most Americans would say no to any further IRS involvement in their lives and no to IRS intrusion into their health care.

I yield the floor. I see the distinguished ranking member of the committee, a distinguished Senator who has been an expert on the IRS and basically bringing reform almost on an individual basis to that agency.

I yield to Senator Grassley.

I would be delighted to respond to my good friend from Maryland. I am in a position to yield back all the minority's time. We have no more speakers.

Will the distinguished Senator yield?

Today, the U.S. Marine Corps is celebrating its birthday. As I speak, the Commandant of the Marine Corps, the Drum and Bugle Corps and various and assorted marines are over in the Russell Building. I am to cut the cake, and I am getting into deeper and deeper trouble if we delay the ceremonies to the degree they could be delayed. If somebody wants to talk, obviously, you have 7 minutes, but I appreciate any consideration you might be able to give us.

I tell the Senator Semper Fi, and on behalf of the minority, I yield back all our time.

Cloture Motion

Mr. President, suddenly I find myself a member of the powerful Appropriations Committee, but it comes under a dark cloud indeed. The distinguished chairman, who does such a great job in behalf of our veterans and military construction, has pointed out the terrible tragedy that has happened at Fort Hood. So I am here standing in, if you will, for Senator Hutchison, who does such a good job, in partnership with my colleague and my friend and my neighbor, whom I respect a great deal. So I appreciate the opportunity to speak on the bill before us.

As Senator Hutchison departs as early as she possibly can to get to Texas to assist in the challenge of this great tragedy, we wish her well, and our prayers are with her and all the people at Fort Hood and all the people in Texas.

As the distinguished chairman has stated, a lot of time and energy have gone into putting this legislation together. Senator Hutchison wanted to thank Chairman Johnson and his staff for working hard to address the needs of our servicemembers and veterans. I am going to repeat just a couple of things that are in the full statement of the distinguished Senator from Texas.

As Chairman Johnson has pointed out, the Military Construction, Veterans Affairs, and Related Agencies appropriations bill includes for fiscal year 2010 $76.7 billion in discretionary spending, $23.2 billion for military construction, $53.2 billion for our veterans, $55.8 billion in mandatory spending for veterans' benefits, and $1.4 billion for military construction projects to assist our troops in Afghanistan in their fight against terrorism.

A lot of the figures Senator Hutchison has here have been mentioned by the distinguished chairman, so I won't go into those, but Senator Hutchison wanted to indicate and wanted to highlight that she was very pleased that the bill provides full funding for the base realignment and closure actions. The funds are essential to bringing our troops home, predominantly from Europe and Korea, and basing them in the United States. By fully funding BRAC, we can help the Department of Defense to stay on schedule to achieve this goal by September of 2011.

Senator Hutchison would also like to highlight that the legislation contains the necessary funds for the Defense Department program especially designed to help our servicemembers who were forced to relocate in this harsh economic housing environment--I might add that we see this at Fort Leavenworth and Fort Riley as well in Kansas--the Homeowners Assistance Fund. Chairman Johnson has been absolutely instrumental in making this program a success.

The legislation contains about $1.4 billion in emergency funding for the war in Afghanistan. Senator Hutchison, myself--almost every Senator knows that the policies of this conflict have been passionately debated on the Senate floor in recent days, but I am sure we can all agree that independent of our views on the war or the strategy of that national security threat, we must provide the infrastructure needs of our sailors, soldiers, airmen, and marines, who, by the way, celebrated their birthday today. This bill does just that.

In addition, I would point out that the distinguished ranking member wanted to express her strong commitment to making sure that our NATO allies--our NATO allies--fund their fair share of these joint projects.

The chairman has already gone over the figures for the Department of Veterans Affairs, although Senator Hutchison did want to point out that it includes funding to enhance outreach and services for mental health care, combat homelessness, further meet the needs of women veterans, and expand our health care to rural areas--something the chairman knows all about, something which I like to think I know something about, and something that I know Senator Hutchison knows about a great deal.

Finally, we have included $48.2 billion in advanced appropriations for veterans' medical care for fiscal year 2011. This funding will allow the VA to better plan the budget for our veterans' health care.

Congress has shown its resolve time and again to care for our Nation's veterans and provide the infrastructure for our men and women in uniform. We all owe them a debt of gratitude and will do our part to take care of them.

So I ask my colleagues to support this bill. We have no objection on this side.

Again, I wish to thank the distinguished chairman for all of his work and leadership.

I yield the floor.

(At the request of Mr. Roberts, the following statement was ordered to be printed in the Record.)

Will the chairman yield?

The chairman has accurately described the contents of the amendment. We have no objection and ask that it be agreed to.

Mr. President, I understand I am allowed 10 minutes of this morning business period; is that correct?

Mr. President, I rise today to share my concerns about the tax increases called for in the health care reform bill that is now being finalized behind closed doors. I want to make sure the American people truly understand what these tax increases will mean for them and their families. This bill calls for an incredible and shocking $500 billion in taxes, in massive new taxes, taxes that will fall on average Americans who already know their tax burden is too high.

We hear a lot about the efforts behind the closed doors to merge three different bills and all the costs and all the efforts to get more voters onboard. But we do not really hear much about the tax increases. They really should make the taxpayer sit up and take notice.

The behind-the-doors crowd has tried to disguise some of the new taxes in this bill by presenting them as being paid for by targeted health care industries. However, the reality is that average Americans who purchase health insurance and use medical services, from prescription drugs to hearing aids, are the ones who will foot the bill for this tax-and-spending spree. The higher taxes called for in this bill come straight out of Americans' pocketbooks. American taxpayers, Americans, have the right to know, they have the right to be informed, they have the right to understand, and they have the right to be heard--not only on the spending, not only on the health care reform bill, but in regard to the taxes they will pay.

Let me give just a few examples of the new taxes called for and who will actually pay them.

The bill imposes a 40-percent excise tax on health insurance providers that offer high-cost health insurance plans. This provision is the largest tax hike in the bill. It raises $201 billion. Of this amount, an analysis by the Joint Committee on Taxation, or the JCT, finds that more than 80 percent or $164 billion of the tax will come from increased income and payroll taxes on higher wages. When the bill is implemented, however, the excise tax is likely to hit 40 percent of American families, so the reality is that these families, not the insurance providers, will be on the hook for the $164 billion.

The bill raises taxes on those who pay for their health care out of pocket by raising the floor for deducting catastrophic medical expenses from 7.5 percent to 10 percent of adjusted gross income. Those who take this deduction are most often seniors and those with serious medical issues. Eighty-seven percent of taxpayers who claim this deduction have income under $100,000.

While an amendment to exempt taxpayers 65 or older from the higher threshold was approved in committee, thank goodness, don't be fooled: the exemption is only in effect in the first 3 years. As a result, in the following years roughly 50 percent of the taxpayers affected by this proposal will be over the age of 65. This makes no sense.

The bill raises taxes on the more than 35 million Americans who participate in flexible spending accounts. The median income of a flexible spending account participant is $55,000. This program is a very important benefit for many families for whom health insurance does not cover, or does not sufficiently cover, some of the highest cost health care expenses, such as dental, vision, and also prescription drug costs. It is also important for individuals who manage chronic diseases such as diabetes, heart disease, or cancer. FSAs allows participants to set aside money out of their own pockets to pay for these necessary expenses. However, under this bill the government caps how much can be set aside in a flexible spending account, a person's own account, effectively raising the tax burden on certain FSA participants and increasing their health care costs--typical of a disguised tax in this bill.

Another tax attack: It also eliminates the ability of individuals to use money from their accounts, the FSA accounts, to purchase over-the- counter medications. Here we are, trying to put downward pressure on health care costs. Rather than maintaining current law that gives consumers the option to purchase over-the-counter medications through a flexible spending account that they have chosen to put money into, the bill instead directs them to more costly alternatives and increased use of the health care system and limits the consumers' ability to fully use their own accounts.

Another example of the stealth taxes called for in this bill is the individual mandate penalty. Although the President has said this penalty is not a tax, the Finance Committee bill adds this provision under a section called the ``Excise Tax on Individuals Without Essential Health Benefits Coverage.'' The government expects to collect $4 billion from this tax.

In 2013, almost half of those Americans who will be paying the penalty tax will have incomes between $22,800 and $68,400 for a family of four. This penalty essentially means the IRS will now tax you if you do not buy a health care plan approved by the government. Let me repeat that. This penalty essentially means the IRS will now tax you if you don't buy a health care plan approved by the government.

Not only that, this bill also expands the reach of the IRS even further into the lives of ordinary Americans, allowing them to collect more information than ever before about you and your health care choices in order to tax you based on these choices. This provision highlights one of the most disturbing aspects of this bill: the increased role the IRS will play in the lives and health care choices of every American.

Under this bill, the IRS will gain unprecedented new powers. But here is the clincher. There is no money in this bill to pay for the expansion of the IRS that will have to occur for the IRS to administer and enforce these new tax provisions--emphasis on ``enforce.'' How much will that cost? How many billions will be needed to pay for this growth in government? How many more employees will the IRS have to hire? We don't know. But make no mistake, every American should understand that the IRS will be playing a bigger role in their life and their health care decisions.

Question, for all those who braved the townhall meetings. Everyone who wants more IRS involvement in their lives, raise your hands. I don't think in these townhall meetings you will hear many hands clapping. Under this bill, not only will Americans see massive new taxes, they will also see an unprecedented expansion of the Internal Revenue Service and a further reach by government into their lives.

This is the wrong solution to health care reform. Americans are looking for real reform that preserves their health care choices. But reform that comes with a $500 billion tax increase and is supervised, if not more, by the Internal Revenue Service is simply not the answer.

Mr. President, I yield the remainder of my time.

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

Mr. President, I rise today to offer legislation with Senator Harkin to fulfill a promise that we made over 30 years ago. We made a commitment to pay 40 percent of the excess cost of educating a special needs child. However, we have not fulfilled that promise.

Our legislation annually increases funding for Part B of the Individuals with Disabilities Education Act over a 6-year period. With these increases, we will be able to fully fund Part B in 2015.

I encourage my colleagues to add their support to this needed legislation. If the Federal Government would provide its promised share of special education funding, our schools could then use any state and local funds for other educational needs, such as art and music.

Mr. President, I rise today to offer legislation with Senator Harkin to fulfill a promise that we made over 30 years ago. We made a commitment to pay 40 percent of the excess cost of educating a special needs child. However, we have not fulfilled that promise.

Our legislation annually increases funding for Part B of the Individuals with Disabilities Education Act over a 6-year period. With these increases, we will be able to fully fund Part B in 2015.

I encourage my colleagues to add their support to this needed legislation. If the Federal Government would provide its promised share of special education funding, our schools could then use any state and local funds for other educational needs, such as art and music.

Mr. President, I ask unanimous consent that the Republican time for the next hour be allocated as follows: myself for 10 minutes, Senator Barrasso for 10 minutes, Senator Crapo for 15 minutes, Senator Wicker for 10 minutes, and Senator Collins for 15 minutes.

Mr. President, I rise today to express my opposition, my considered opposition, to Judge Sonia Sotomayor's nomination to the U.S. Supreme Court.

As Senators, I think we all know we have an obligation to ensure that our courts are filled with qualified and impartial judges.

While Judge Sotomayor has an impressive resume--that is a given--I am concerned that her personal judgments and views will impact her judicial decisions. In addition, I find some of her rulings very troubling.

During the Senate's debate on the nomination of Chief Justice John Roberts, then-Senator Obama stated:

that while adherence to legal precedent and rules of

statutory or constitutional construction will dispose of 95

percent of the cases that come before the Court, so that both

a Scalia or Ginsburg will arrive at the same place most of

the time on those 95 percent of the cases, what matters on

the Supreme Court is those 5 percent of cases that are truly

difficult. In those cases, adherence to precedent and the

rules will only get you through the 25th mile of the

marathon. That last mile can only be determined on the basis

of one's deepest values, one's core concerns, one's broader

perspectives on how the world works, and the depth and

breadth of one's empathy.

Thus the entrance of the ``empathy'' issue to this debate. I respectfully disagree with now-President Obama.

Judges must decide all cases in adherence to legal precedent and rules of statutory or constitutional construction. It does not mean if they do that they do not have empathy. I agree--and I think everybody would agree--everybody on the Supreme Court has empathy. But the role of a judge is not to rule based on his or her own personal judgments but to adhere to the laws as they are written.

While Judge Sotomayor stated during her confirmation hearing that ``it is not the heart that compels conclusions in cases, it is the law,'' I still have concerns regarding her ability to remain impartial. She has made some statements in Law Review articles and speeches that are of serious concern. I

am not convinced that Judge Sotomayor will set aside her personal judgments and views.

While on the Second Circuit Court of Appeals, Judge Sotomayor joined a four-paragraph ruling on property rights. In Didden v. Village of Port Chester, the appellants claimed that a developer demanded $800,000 in order to avoid condemnation of the property by the city. When the appellants refused to pay the $800,000, they received a petition to initiate condemnation. Although the Second Circuit Court of Appeals dismissed the case, it was noted that relief could not be granted based on the U.S. Supreme Court's decision in Kelo v. City of New London. That four-paragraph ruling didn't even provide an in-depth analysis as to how the Kelo ruling applied to the facts at hand. In fact, the Kelo decision acknowledges that ``a city no doubt would be forbidden from taking land for the purpose of conferring a private benefit on a particular party.''

The four-paragraph ruling in Didden is very troubling. In Kansas, land is gold; farmland is platinum. We have a healthy respect for property rights in Middle America. It also bothers me that a court could make a broad statement without analyzing and applying the facts to case law.

Turning to firearm rights, Judge Sotomayor joined an opinion ruling that the second amendment is not a fundamental right and, therefore, does not apply to State and local governments. It is likely that at some point the second amendment's application to States could be argued before the Supreme Court. That could come very quickly. I would certainly hope that should this matter be argued before the Supreme Court, Judge Sotomayor would recuse herself. During her hearing, she did not indicate whether she would recuse herself in any decision. That was not, however, the case during the nomination hearings of Judges Alito and Roberts.

I do not discount the fact that Judge Sotomayor is a very accomplished judge and has an extensive judicial record. However, some of her statements, writings, and rulings concern me. They indicate her personal judgments and views may impact her judicial decisions. We have a constitutional obligation to ensure that our judges are impartial and faithful to the law.

During Chief Justice John Roberts' confirmation hearing, he noted:

Judges and justices are servants of the law, not the other

way around. Judges are like umpires. Umpires don't make the

rules. They apply them. The role of an umpire and judge is

critical. They make sure everybody plays by the rules [not by

empathy], but it is a limited role. Nobody ever went to a

ball game to see the umpire.

I am not convinced that Judge Sotomayor will be an umpire and consistently adhere to the rule of law as opposed to empathy.

For these reasons and others cited by some of my colleagues, I oppose her nomination.

I yield the floor.

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

Mr. President, I find myself in a rather unique position here. If you look in the bio sections of all of the outfits that keep herd on us, they will record me as a journalist. That is an unemployed newspaper man, by the way.

But I have a great family tradition in journalism, three generations, four generations, actually, of the Roberts family and the State's second oldest newspaper in Kansas. I still carry around my reporter's notebook, have great respect for those of the fourth estate. We shine the light of truth with our own individual flashlight.

I do not think I have ever done this in 28 years of public service, but I am irritated. I am more than irritated. I rise today to clear up some recent flagrant mischaracterizations about Medicare payments, especially since the Medicare payments are now being used as a target as a pay-for for the health care reform, the alleged health care reform that Senator Enzi was talking about, specifically the statements made on the front page of today's Washington Post, the fountain of all knowledge here in Washington, in an article entitled ``Obama Eyes the Purse Strings for Medicare.''

I would describe this article--I read it. I read it again. I was a relatively happy person, watching the weather--I do not watch the news much--had my cup of coffee, was going to turn to the sports pages. Then I happened to glance at this, read it, and ruined my whole morning. I came in, I was mean with the staff and everything else. So I thought I better get it off my chest.

This article is patronizing. It is condescending. The bad part about it is it is egregious in nature and effect at a crucial time in the health care debate, and that is most unfortunate.

The author of this article describes what she sees as ``one of the most effective and lucrative forms of constituent service,'' i.e. setting reimbursement rates for local hospitals, doctors, home health care centers, and other health care providers.

Oh, I wish I had that power, as opposed to CMS, which is the subagency, the acronym agency for the Department of Health and Human Services, that does set reimbursement rates for all health care providers in the United States.

The author continues, accusing ``longtime Members of Congress'' of such atrocities as ``championing New York City's teaching hospitals'' and making sure ``rural health services are amply funded.'' In this author's mind, these hospitals and other providers are ``flush.'' Flush with Medicare cash as a result.

I must admit in my 28 years in Congress, I have absolutely been one of those dastardly Members intent on making darn sure that the rural health care delivery system can remain alive and serve our people, even if it has to be kept on life support, which is the true characterization of what we face.

I wonder, since it never appears anywhere in the person's article, in her article, if the author of this piece is aware that the average Medicare reimbursement rate for doctors is about 80 percent of what the commercial market pays or that Medicare only pays about 70 percent of the market rates for hospitals. That is why we have hospital after hospital after hospital for decades in Kansas passing bond issues just to keep their doors open. These are not flush places. These are not posh places in regard to hospitals.

Then I go back to the fact that doctors get paid 80 percent. That is why doctors, many of them, are refusing to take--in regard to Medicare--patients. And that is that terrible word that people say is too scary, that is called rationing, that when we set a reimbursement rate, we, meaning the CMS--no, not individual Members of Congress, as the article infers--but these agencies cannot reimburse doctors enough so they can make a living, or other health care providers, that they cease providing Medicare to seniors.

What does the senior do then? Well, they are in a very difficult situation. How do you think these providers survive? The answer is that they shift that loss onto the private market to the tune of nearly $90 billion a year.

Let me repeat that. Everybody who goes to the hospital, everybody who goes to a doctor and has private insurance, you are paying $90 billion a year in a hidden tax in regard to the people who basically are not covered by Medicare and by Medicaid, if, in fact, you would do what the President has suggested, and maybe take some money--``eyes the purse strings for Medicare,'' Medicare being a target, Medicare being the service for seniors. Wake up, seniors. Wake up, AARP. Wake up, everyone else in the health care field. We are targeting Medicare.

My word, if any Senator had come down here except during these last 6 months and said: Let's cut Medicare by 10 percent, they would have been excoriated by this newspaper for hurting senior citizens.

Well, in my State of Kansas and in other rural States across the country, we do not have a private market to shift those losses to. Our rural areas do not have the population base to support such a cost shift as $90 billion as happens in the rest of the country. In addition, the folks in these towns are much more likely to depend on Medicare or Medicaid or to simply be uninsured. In short, without some sort of special payment from Medicare, these hospitals would not survive.

You tell me, Washington Post, what you would say to the residents of Smith Center here, top center in Kansas. What would you say to the residents of Smith Center if their hospital closed?

Smith Center is a great town, close to the geographic center of the lower 48 States, has a population of a little less than 2,000 people. They have a great football team, high school football program, Smith Center Redmen, the pride of north central Kansas, one of the greatest small town football teams in America.

The town is served by the Smith County Memorial Hospital, a critical access hospital with 25 beds. For those of you who are unfamiliar with the terminology, a critical access hospital is a rural hospital with 25 beds or less which is at least 35 miles away from another hospital and which provides 24-hour emergency services.

Critical access hospitals get special treatment under Medicare. They get paid 101 percent of their costs for inpatient, outpatient, and swing-bed services. I probably should not mention that or this reporter might run out to Smith Center and say: My goodness, you are getting 101 percent. Sure. She should go out and take a look, and talk to the hospital administrator and the people in that hospital.

In other words, they do not get the usual 70 percent of the market rate reimbursement for Medicare, for a very good reason, because of the distances they would have to travel. Without the critical access hospital program, the closest hospital for the residents of Smith Center would be all the way in Hays, KS, America, right down here 90 miles away. You tell me what a person's chances of survival are after a car accident or a tractor accident if they have to be driven 90 miles away for emergency care.

Smith County Memorial is just one of 83 critical access hospitals in Kansas. They are absolutely essential to the very lives of the people in rural America. Indeed, they are essential to the very existence of rural America at all.

I have the privilege of being the cochairman of the Rural Health Care Caucus, along with Tom Harkin of Iowa. We are fighting tooth and nail, holding on by our fingernails to exist, to provide care to the people who live in these small communities.

I am happy to admit it, I am happy to admit to this reporter--I hope she comes in for a cup of coffee. I would be happy to give her a cup of coffee, no cream or sugar; there might be a little vinegar in it. But at any rate, please come in for a cup of coffee and visit about this. I am happy to admit it. I will bend over backward to preserve the payment rates that allow these hospitals to stay open and to continue to serve the people in Smith Center, KS, and elsewhere all throughout rural America.

I believe this position is completely justified. I sleep just fine at night knowing that I have used my so-called influence through legislation, through the rural health care coalition, through the Finance Committee, through the HELP Committee, to ensure that Medicare pays these hospitals just enough to average a 1-percent Medicare margin, 1 percent, when these hospitals are still fighting for their lives.

I would like to personally invite the author of this article or any other member of the Washington Post editorial board, God love them, to visit some of the rural hospitals in Kansas with me. The reporter's name--I hope I get it right; I apologize if I do not. I really sort of apologize. I am picking on her--is Shailagh Murray.

Shailagh, why don't you come to Kansas with me and let us go out to Smith Center. Here is the hospital. This is this posh resort that you apparently think we finance with Medicare.

It is true, you know, you go through the doors, there are two-inch thick carpets, you go in, there is--let's see, I think there is Mozart's piano concert 21, piano concert No. 21, and they call you by your first name, and you get immediate treatment. Then there are massage facilities and a spa in the back. And that is a lot of what we have in our Dodge City feedlots. That is not the case.

Talk to the CEOs, the doctors, the nurses, and the patients. Walk around this small hospital and see the equipment and the facilities. Flush with the Medicare cash? Come on. And flush with Medicare cash that is somehow influenced by individual Members of Congress? I wish. I have been fussing and fighting and feuding and pleading and cajoling with CMS to try at least to get these payments to doctors and hospitals up to the level that they can continue to exist.

Flush with Medicare cash? I think not.

Look at this hospital. Do you see anything that would lead to a description of this sort? I am not too sure anybody is going to give up their vacation. They have the finest people in the world. That is our best commodity in rural areas. I am not picking on Smith Center. They are doing a fantastic job with the resources they have. But it just makes me very angry that a Washington, DC, paper and reporter would demonize a program that keeps rural America's heart beating. It is a patronizing and dead-wrong description, and it offends me and the people I am privileged to represent in rural Kansas.

I want to tell Shailagh, Ms. Murray, I am never going to stop fighting for these hospitals no matter how many deals the American Hospital Association cuts with the White House, no matter how many ugly articles are written here in DC. I am rather amazed at the deal the American Hospital Association allegedly cut--$155 billion in cuts to Medicare for senior citizens. Wake up; it is your Medicare. There is going to be more rationing when doctors say: I am sorry, I just can't afford to continue.

That is the target now on the Finance Committee--Medicare. I never thought I would see the day that would happen. But I will not stop fighting for these hospitals. Here we have the American Hospital Association, the Kansas Hospital Association, the Missouri Hospital Association, other hospital associations are not happy with the national association when you crawl in bed and get fleas with the administration. What is the old saying? If you go to bed with the Federal Government, you wake up in the morning and you got something more than a good night's sleep. And that is exactly what has happened with the American Hospital Association.

They come through my door and say: Help, help, please get these reimbursement rates up. Every year, we have done that with Medicare and the Medicare Programs. We are being cut by 11 percent, and the cost of inflation in regard to where we try to practice has gone up 7 percent, and whatever other number they said every year. They blame Republicans. Once in a while, they blame Democrats and say: Why on Earth did you cut Medicare? And now we are using Medicare as a target for health care reform for this bill that is impossible for most people to even comprehend? It is amazing.

The American Hospital Association bought into it with $155 billion in cuts. They come through my door every year when they want to keep the reimbursement rates level. Don't come through my door for at least a month until I calm down. That is my duty to the people of my State. I feel comfortable with that.

I have been a little tough here on a reporter I have never met, obviously. She is spending a lot of her time in the people's house talking with mucky-mucks on the various committees. Those are people with the seniority. I used to be one of those. I used to be somebody. But I urge her to talk to Members who represent rural areas and the rural health care delivery system and understand that this is not a question of this hospital having flush payments. They are hanging by their fingernails just to keep open. It is not true that Members of Congress, even the distinguished Presiding Officer and anybody else who might happen to be listening to my remarks, the great Senator Thune standing to my rear who also represents rural areas and has even a sparser area than I do--it is just not true. This article comes right at the apex of the debate of the health care reform debate. It is just not right.

Let me again say to Shailagh: Why don't you come out to Kansas with me. We will visit with Tom Bell, president of the Kansas Hospital Association. We can go out to Smith Center and visit the hospital or as many hospitals as you want. We will see who is flush in regard to Medicare payments. That is certainly not the case with them.

I think I have made my point. I must say, as a former journalist, former newspaperman, I used to check my facts. I would ask that they do the same.

I yield the floor.