Floor Statements

I will answer my colleague as somebody who has practiced medicine for 25 years: MedPAC, last year, said 29 percent of Medicare beneficiaries it surveyed were looking for a primary care doctor and had great difficulty in finding somebody to treat them.

That is now. In the State of Texas, 58 percent of the State's doctors took new Medicare patients, but only 38 percent of the State's primary care doctors took new Medicare patients.

I would make the case to you that if you delay care, that is denied care. It is exacerbated in our older population because an older person with a medical need is much more susceptible to the complications that can come from that initial problem. So if you delay the care, you are denying the care and you are actually increasing the cost.

There are 15 million people in this population. I have no idea if their plans include all of them. But if you add 15

million new people to Medicare, what you are going to have is 50 percent of them are not going to find a primary care physician to care for them because the rate of reimbursement does not cover the cost of care.

I think the editorial you quote is exactly right.

I would also note, if I may, that President Obama loves the Mayo Clinic, and rightly so. I had a brain tumor removed the summer before last by the Mayo Clinic. I am standing here on the Senate floor because of their expertise.

I will ignore that comment.

The fact is, what Mayo says is we have to figure out how we create incentives in terms of how do we get people cared for at a lower cost. Medicare is not the way to do it.

As a matter of fact, I heard our colleagues talk. We have had eight votes since last Saturday. We are ready to vote. This is a 2,074-page bill. I have 15 amendments in the queue. I want to vote on them.

They don't want to vote because they don't want the American people to hear all the bad things about what is going to happen to their health care if this bill passes. If we do Medicare, what is going to happen is Medicare costs are going to skyrocket, but access is going to go down.

If the Senator will yield, there are some things we could vote on. President Obama outlined some very specific things that ought to be in this bill. We ought to vote to put them in the bill.

What he said he wanted and what this bill presents are two different things. We ought to vote on making sure everybody has access. We ought to vote on making sure we are under the same plan as everybody else we are going to put into any new expanded health care coverage. We ought to vote in making sure everybody is treated fairly in this country. We ought to vote on your prescription drug reimportation. We ought to vote. But what we are doing is we are getting a slowdown.

We heard we are obstructing the bill. We are not obstructing the bill. Any other bill that comes before this body that had 2,000 pages in it we would allot 8 weeks, 10 weeks to debate.

As our colleague from Maine knows, there is not a more complicated subject that will affect more people that this body has ever taken up. We are trying to squeeze that into 3\1/2\ weeks, and the last 2 weeks we don't know what is in the bill.

Time out.

They are going to cut care. We are going to have more complications and worse outcomes. That is what is going to happen. Rather than changing the payment formula, which is what we should do, by rewarding quality and rewarding outcome, rather than rewarding flipping a switch, that is what needs to happen. We are going to take the same antiquated system, we are going to cut $465 billion from it, and then we are going to add, as my colleague from Tennessee said, it is 34 million people, if they include everybody from 55 to 64 in the same program.

Care is going to be impacted. Here is a survey of 90,000 physicians. That is more than the active practicing physicians of the AMA. More than 8 in 10 physicians surveyed think payment reform is best to improve the system for all Americans. Only 5 percent of the physicians surveyed rated the current government health care program as effective, 5 percent.

Mr. President, I stand confused from the statement of the chairman of the Finance Committee because we have all the reports that the bill he is talking about is not the bill we are going to be voting on because we are totally changing what we are doing. What is out there now is that we are going to expand Medicare to those down to 55 years of age, and we are going to expand Medicaid up to those of 150 percent of poverty. We are going to add billions of dollars of mandates, even at 90 percent copaid by the Federal Government, to the States over the next 10 years. We have a Medicare Program that you have taken $465 billion out of, and you are going to add 34 million new people to under the new plan--the new plan we are talking about. You are talking about the plan we used to have.

It is interesting, though, as you make those points, when you say it is net tax cut. Three-quarters of the net tax cut goes to people in this country who pay no taxes in the first place. The chairman cannot deny that. The fact is, according to the Joint Tax Committee--the chairman conveniently does not look at the other body that gives us information on taxes. According to the Joint Tax Committee, $288 billion of the $394 billion will be refundable. That is a refundable tax credit to people who are paying no taxes now.

The fact is, it is taxes to the average American family-- 40 million of them. According to the Joint Tax Committee, taxes will rise on those who are making under $200,000 a year. The Joint Tax Committee said that.

The point is, what you are talking about does not have any application because we do not have ``the bill,'' again, because we have a new ``the bill'' on the floor, which is going to take a bankrupt program that our children today are responsible for--if you are born today, based on the unfunded liabilities of Medicare, you are responsible for $350,000, if you are a new child born today, for what we have not paid for in Medicare. And now we have the new plan that is going to come out. We have cut $465 billion out of Medicare, or moved it out of Medicare, to create a new program. And we are going to add 34 million new Americans to it, in a plan that has already mortgaged the future of our children.

The other thing the chairman said is that costs in health care will go down and that premiums will go down. Well, there are 11 out of 12 people who have studied ``the plan'' who say premiums will rise. What CBO says is, if you are in the individual market, your premiums are going to go up anywhere from 10 to 13 percent. In fact, they are not sure whether premiums will decline. They say on the other groups it is from a 1-percent increase to a 2-percent decrease over what they would have already increased.

So our problem with health care is costs. That is the thing that stops access to health care in this country. And the plan--whether it is the new plan, which nobody has gotten to see the details of, or the plan we have seen the details of, the 2,074 pages we have seen the details of--raises the cost of health care in this country.

But none of that is important because the most important thing is, it puts government in control of your health care through the task force on preventive health services, through the Medicare Advisory Commission, and through the cost comparative effectiveness panel. So with a wink and a nod we are going to put government in control of your health care; we are going to put 70 new bureaucracies between you and your doctor; we are going to put 20,000 new Federal employees between you and your doctor; and we are not going to lower the costs. The average American is not going to get a tax cut; they are going to see an

increase out of this bill. The average middle-income American is going to see a tax increase out of this bill.

So, consequently, what we have heard sounds good on the surface. But the most important thing to remember is you are no longer going to be in control of your health care because once the government puts its nose under the tent, just as it did on breast cancer screening--and we have the gall to say we are going to recognize every time the agency does something that is harmful to a patient in their relationship with their doctor, that we are going to come to the Senate floor and correct it. The fact is, that isn't going to happen.

So, ultimately, your health care is going to cost more and your premiums are going to rise. Eleven out of the twelve studies say premiums are going to rise under the bill that is before us, and the people who get the tax cuts are the people who aren't paying any taxes now. To pay for those tax cuts, taxes are going to rise on 40 million American families who earn under $200,000 a year.

Mr. President, I yield the floor.

I thank my colleague from Idaho.

Mr. President, the majority whip realizes there is an alternative bill. As a matter of fact, there are four alternative bills out there. They were not given a hearing. They did not have the resources. They did not have the CBO that would score them.

We have a bill that guarantees if you like what you have now, you can keep it; has absolutely zero tax increases on American families; no increases in taxes on American business; lowers the cost of everybody's health insurance premiums; covers preexisting conditions, period; protects seniors' high-quality care and choices; increases personal control over your own health care; no Medicaid expansion, but, in fact, puts Medicaid patients into true coverage without discrimination and allows all the doctors in this country to see them. It protects the physician-patient relationship and empowers patients, families, and physicians and providers. It does not empower the government. The majority whip knows that. Yet we have just heard on the floor we have not offered anything.

We have offered a bill that outside evaluators say saves the States at least $1 trillion in the first 10 years, saves the Federal Government $70 billion, treats everybody the same, creates access to health care, and, more importantly, it incentivizes prevention and the management of chronic disease and, finally, it attacks some of the $100 billion a year in fraud in Medicare and Medicaid, where this bill attacks less than $400 million a year in Medicare and Medicaid.

I yield back to the Senator.

I would respond to the Senator from Arizona in the following way. First of all, they won't understand that language. But more importantly, if you look at the law, there is Medicare Part A, Medicare Part B, Medicare Part C, and Medicare Part D. They are all law. They are all law. What is guaranteed under the law today is that if you want Medicare Advantage, you can have it. What is going to change is that we are going to take away that guarantee. We are going to modify Medicare Part C, which is Medicare Advantage.

So we have this confusing way of saying we are not taking away any of your guaranteed benefits, but in fact, under the current law today, Medicare Advantage is guaranteed to anybody who wants to sign up for it. So it is duplicitous to say we are not cutting your benefits, when in fact we are.

Let me speak to my experience and then I will yield to my colleague from Wyoming, who is an orthopedic surgeon.

What is good about Medicare Advantage? We hear it is a money pot to pay for a new program for other people. Here is what is good about it. We get coordinated care for poor Medicare folks. Medicare Advantage coordinates the care. When you coordinate care, what you do is you decrease the number of tests, you prevent hospitalizations, you get better outcomes, and consequently you have healthier seniors.

So when it is looked at, Medicare Advantage doesn't cost more. It actually saves Medicare money on an individual basis. Because if you forgo the interests of a hospital, where you start incurring costs, what you have done is saved the Medicare Trust Fund but you have also given better care.

The second point I wish to make is that many people on Medicare Advantage cannot afford to buy Medicare supplemental policies. Ninety- four percent of the people in this country who are on Medicare and not Medicare Advantage are buying a supplemental policy. Why is that? Because the basic underlying benefit package of Medicare is not adequate. So here we have this

group of people who are benefitted because they have chosen a guaranteed benefit of Medicare Part C, and all of a sudden we are saying: Time out. You don't get that anymore.

A lot of them are rural. I don't know the income levels, but I know there is a propensity for actually getting a savings, because you don't have to buy a supplemental policy if you are on Medicare Advantage.

And we heard from the freshman Democrats that they want to put a new preventive package into the program. Yet they want to take the preventive package out of Medicare Advantage. It is an interesting mix of amendments, isn't it?

I wonder if the Senator is aware, in Alabama, there will be 181,000 people who will get a Medicare Advantage cut; in California, 1,606,000 seniors are going to have benefits cut; Colorado, 198,000; Georgia, 176,000; Illinois, 176,000; Indiana, 148,000; Kentucky, 110,000; Louisiana, 151,000; Massachusetts, 200,000; Michigan, 406,000--that is exactly what Michigan needs right now, isn't it, for their seniors to have their benefits cut--Minnesota, 284,000; Missouri, 200,000; Nevada, 104,000; New Jersey, 156,000; New York, 853,000; Ohio, 499,000; Oregon, 250,000; Pennsylvania--maybe, maybe not because they may have the deal--865,000; Tennessee, 233,000; Washington State, 225,000; Wisconsin, 243,000.

I ask unanimous consent that the list of what the enrollment is by CMS on Medicare and Medicare Advantage enrollment, as of August 2009, be printed in the Record.

Absolutely.

Limited prevention screening, no coordinated care, loss of access to certain drugs, loss of accessory things, such as vision and hearing supplementals, but, more importantly, poorer health outcomes. That is what it is going to mean--or a much smaller checkbook, one or the other. A smaller checkbook because now the government isn't going to pay for it--you are--or poorer health outcomes. If your checkbook is limited, the thing that happens is, you will get the poorer health outcome.

That is $2,000 a year.

I will make one other point. Over the next 10 years, 15 million baby boomers are going to go into Medicare. We are taking $465 billion out of Medicare; on the 10-year picture, $1 trillion. So we are going to add $15 million and cut $1 trillion. What do you think is going to happen to the care for everybody in Medicare? The ultimate

is, we are going to ration the care for seniors, if this bill comes through.

Will the Senator yield for a question?

Mr. President, the question I was going to ask the distinguished Senator from Massachusetts is, how many Medicare Advantage patients has he ever cared for? How many Medicare Advantage-- how many Medicare patients has he ever cared for? How many times has he been in the trough, experiencing the heavy hand of government as we try to care for people on Medicare? The answer to that question is zero because he is not a physician. He relies on the American Medical Association--the American Medical Association that today represents less than 10 percent of the active practicing doctors in this country. He relies on AARP, which has 40 million in membership but is the fifth largest revenue receiver from supplemental policies. That is whom he relies on. The fact is, he does not have the experience of being in the trough, caring for patients.

Let me tell you what is going to happen to Medicare Advantage patients.

The Senator would not yield to me. I have no intention to yield to him.

The Senator would not yield. I will continue my talk.

For Medicare Advantage patients--there is no question, I have agreed with the chairman of the Finance Committee--the competitive bidding needs to happen. But there is one little thing that happened on the way to the bank. It is that there is going to be a decrease in benefits-- not only a decrease in what we pay for, but there is going to be a decrease in benefits. Where will that impact be most importantly felt? Not in the urban areas. It is not going to be felt in the urban areas. It is going to be felt in rural areas throughout this country. That is where it is going to be felt. It is going to be felt out there where there is a marginal rural hospital that is using the other benefits to help maintain the flow to that hospital.

So there is no question that, if you are one of the 11 million--with the exception of those who got deals cut in this bill--that, for sure, the 90,000 Oklahomans are going to feel an impact from this cut.

Nobody says Medicare Advantage is perfect. It is not. It is far from it. But there is another aspect of Medicare Advantage that really helps those on the lower rung of the economic ladder. It is that with Medicare Advantage, they did not have to buy a supplemental policy because all the things they need are covered.

Ninety-four percent of Americans on Medicare who are not on Medicare Advantage purchase a supplemental policy. Why do they do that? Why do they spend $300 or $400 a month to buy a supplemental policy? Because basic Medicare that we have proudly said will not be cut does not cover the basic needs of a senior and their health care. Consequently, they pay into Medicare Part A, HI trust fund their whole life, they buy Medicare Part B, and then they buy a supplemental policy. It just so happens that one of the largest sellers of those policies happens to be somebody who is endorsing this bill. If that is not a conflict of interest, I don't know what is.

I heard the Senator talk about Massachusetts. I refer to an article from the Chicago Tribune--they have broadened care. I am proud of them for doing that. But at what cost? At a 10-percent increase in cost of premiums for the people in the middle.

When we go back to what the President said about what his goals are, there is no question that this bill does not keep those promises.

I now ask unanimous consent to turn to another area which we have discussed and ask unanimous consent to have printed in the Record an article from the North County Times/The Californian, dated December 5, 2009, at 9:35 p.m.

I will offer you the same courtesy you offered me. When I finish my remarks, on your time, you are more than welcome to refute what I said.

I ask unanimous-consent that be printed in the Record.

In this bill, what we are debating are three terrible things for care but great things for cost: the U.S. Preventive Task Force on Prevention Services, the Medicare Advisory Commission, and the references to the Cost Comparative Effectiveness Panel.

When the U.S. Preventive Services Task Force came out with their recommendation, as far as costs--I am talking about breast cancer screening for 40- to 49-year-olds--as far as costs, they were absolutely right, as far as cost-effectiveness. But as far as clinical effectiveness, they were absolutely wrong. What did we do? We accepted a Vitter amendment to hold off, so that recommendation, that mandate from that panel will not apply to women in this country under these programs--except the women in California on Medi-Cal because, you see, this week California embraced the U.S. Preventive Services Task Force. So if you are a Medicaid patient--which we are going to put 15 million more people into--you cannot have a mammogram in California if you are under 50. You cannot have it because, from a cost standpoint, they are right. From a clinical standpoint, they are wrong.

What we have done is, every time one of these three organizations creates a ruling, that the American people rise up and say: That is wrong, we are going to come in here and correct it? But throughout this bill, strung throughout are multiple references to what these three panels are going to ration--I did not miss that word--ration the care to American people in this country.

If you are a senior, you have two real reasons to be worried. One is, we are cutting Medicare. And if we are not, then vote for the Gregg amendment and you will make sure we don't. It is an insurance policy. But more important, within that, we are going to see the care to seniors rationed based not on what is in their own best interests or their health's best interests but what is in the cost's best interests. There is no question about it. We are going to do that.

It would be different if we created a comparative effectiveness panel, a clinical comparative panel. But they are already out there. We knew that.

When I study to take my recertification exams, I have to know what the clinical comparative effectiveness guidelines are or I will not pass as a practicing physician. But we didn't do that. We said: Cost is most important. So how are we going to cut? We are going to say where something is cost-effective though not clinically effective, we are going to cut that care.

So if you are a senior, especially if you are on Medicare Advantage, you don't have to just worry about the fact that we are going to decrease the revenue stream that will supply those benefits that cause you not to have to buy a supplemental policy, and we are going to decrease some of the things that are available to you as a Medicare Advantage patient, but you also have to worry about the next ruling that is going to come from the U.S. Preventative Health Services Task Force. You have to worry about what is going to come from the Medicare Payment Advisory Commission because it is going to be looking at costs too.

Then you have to worry about what is going to come from the cost comparative effectiveness panel. I could spend up to 8 hours talking about tragedies from England and Canada on care denied based on things Americans have today that that very panel is going to deny to Americans in the future because they are not cost-effective. That is one of the reasons our result in terms of cancer treatments is one-third better than anywhere else in the world. It is because we don't have mother nanny bureaucracy saying what you can and cannot have.

It would be totally different if we created incentives for lowering the cost, but we don't. We create mandates. We drive down the cost of health care in specific areas through these three separate panels.

There is one thing that is even worse than the two things I just talked about for Medicare patients. Here is what it is. When you have these three panels, you have just taken away the loyalty of your physician to you. You have just decided, with these three panels, that the physicians have to keep their eyes on the government. They have to do what the government says is in your best health interest rather than what that provider knows is in your best interest. Remember, the Medicare Payment Advisory Commission, the cost comparative effectiveness panel, and the Preventative Services Task Force doesn't know your family history, doesn't know your clinical history, has never done an exam on you, do not know the idiosyncrasies of your health care. But we are going to apply that all to you; we are going to depersonalize health care.

I readily admit, for 80 percent of the people, it is going to be just fine. They will not see any untoward result. But I will predict, as a practicing physician for over 25 years, for that remaining 20 percent it is going to be a disaster as far as their personal health is concerned. It will destroy the patient-doctor relationship. It will give us worse outcomes, and it will not save us any money because the consequences of those decisions will create a complication which will require more dollars expended.

When we think the government can practice medicine--and that is what this bill does; this bill sets up the government to practice medicine-- we might as well hang it up and just be ready because 20 percent are going to get substandard care compared to what a Medicare patient receives today. We are going to get sicker. The life expectancy of people under this health care bill will decline. The quality of care will decline. The innovation of new advancements in health care will decline because we have chosen the government to decide what everybody will get. It is a disaster as far as the individual patient is concerned.

That is not the motivation of my colleagues on the other side. I know that. I am not accusing them of that. But what they don't see, sitting in Washington, is what I see in a clinic office practice in medicine. Medicine is intensely personal. It ought to be about your choice, about what is best for you and your family and your children, not what the government says makes the best economic sense to the budget picture in Washington any particular year. When we lose that quality in American medicine, we are going to lose the best of what we have in the name of fixing what is wrong.

I agree with my colleagues the insurance industry has a lot of stink to it. But there are a lot of ways to fix it other than the way we have done. I agree with my colleagues that my profession is not pure at every turn of the corner. I agree with my colleagues we can do better. But when we write a bill that is absent any absolute clinical judgment left to the practice of medicine by those who know the patients best, who have 100 percent of that patient's best interests at heart, we are going to hurt the quality of care. We are going to hurt it significantly. Your motivations are good. The answers are wrong on a clinical basis.

Now to the Gregg amendment. The Gregg amendment does what you all say you want to do. I remind my colleagues the Medicare trustees are highly suspicious of the Medicare cuts in this bill. What they say is, they highly doubt it will ever happen because it has never happened before because there is not the political will to decrease the dollars in Medicare. More importantly, the dollars are going to come out of care instead of out of fraud. There is only $2 billion, say, out of at least $100 billion a year, in fraud. Only 2 percent of it per year is coming out. That is the problem. We could have had a Medicare bill and we could have cut $60 or $70 billion of fraud together out of this bill. We can come together on that. We could have cut $720 billion out of Medicare just based on fraud alone without ever touching Medicare Advantage, without ever giving sweetheart deals to the people in Florida because their Senator wanted it, without ever touching FMAP adjustments in other States.

We could have done that, but we chose not to. We chose what we know up here rather than what we know in the hinterland, those of us who are practicing medicine. What do we know? We know there are some rip-offs in home health care. We know there are significant rip-offs in durable medical equipment. We know there are some rip-offs in hospice. We know there are drug company rip-offs. We could agree to some of those. We actually even know in large hospitals that there are some problems there as well. But there are very few problems in our rural hospitals because they are struggling just to keep the doors open. We could have done that, but we chose not to. So we have this divide, and we are going to fix it one way. The biggest pot of honey in Medicare is fraud. Everybody knows that. But we are not going to fix it.

If, in fact, what my colleagues claim is true, that these are Medicare cuts that nobody will ever feel any consequence from, in spite of my own years of practice and knowing the difference, that that isn't true, but let's give you that, why would we not put it all back in Medicare so we don't steal from our children and our grandchildren? Why would we not do that? We have chosen not to do that. We have chosen to mix it. And it is honorable to try to create a system to get more people insured. Yet we will still have 24 million people not insured. Out of this bill, we will still have 24 million people not insured, when it is all said and done, if everything goes as planned.

Yesterday I introduced into the Record the analysis by the State insurance commission in the State of Oklahoma. Kim Holland is of your party, the majority party. But she sees what is getting ready to happen with this bill. What does she say? What she says is, insurance premiums are going to significantly rise in Oklahoma. More people will be uninsured than there are today. The State Medicaid fund is going to be tremendously stressed with at least $67 million a year having to go into that, again, based on the mandates in this bill that we don't have money to do; that, in fact, it is not the way to solve what Oklahoma is facing in terms of health care.

I didn't call her and say: Give me something bad to say about this bill. She volunteered this information out of her legitimate concern for the consequences, of what is going to happen with this bill. Why would she do that? Because she knows one heck-of-a-lot more about insurance than I do and anybody else in this body. She knows it in our State. And the other insurance commissioners around here, some through their association, have endorsed this bill. Most, when they look at their State, especially the poorer States, especially West Virginia, it is going to hurt.

How are we going to cover that? We are going to shift 15 million people to Medicaid. What do we know about Medicaid? I have delivered thousands of babies and over half of them have been Medicaid. I have cared for thousands of Medicaid children, thousands of Medicaid adults and thousands of Medicaid patients. What do we know? Medicaid is a substandard program. Compared to everybody else, it is substandard, except when compared to the Indian Health Service, and that is a disaster. So our answer is to put a mandate on the States that they cannot afford and shove another 15 million people into a system that has poorer outcomes, higher complication rates, higher infant mortality rates, later presentation, and a system that has 11 million people eligible for it today who are not signed up.

We have the system out there, but they are not signed up. So they are not getting any preventative care. They are not interacting with a primary care physician.

And that is our answer? Move 15 million more Americans into Medicaid. By the way, keep a discriminatory stamp on their forehead, rather than give them an insurance program; put a stamp on their forehead that says 40 percent of the doctors can't see you, 65 percent of the specialists will not see you because your reimbursement rate is so low they can't afford to have you walk into their office and cover the cost of seeing you. That is what we are going to do.

That is not reform to health care. That is banishing people to a substandard system as compared to what the rest of the system is and then feeling good about it. That is not reform. That is discrimination because here is what really happens to a Medicaid mom and her children.

If she has a sick kid, she can't get in. She has this 6-year-old with a fever, not eating, dehydrated, and she can't get in to see a primary care physician, which could keep that child out of the hospital. So what happens? She keeps trying to get in. What does she do? She accesses the emergency room, the most expensive place. She accesses it late--not early, late.

So we have a sicker child, with higher costs, because we have a system that will not reimburse its costs. And you all have actually talked about the cost shift on that, from Medicare and Medicaid, to the private sector. We would be much better off paying the same rates in Medicaid so we do not get that cost shift, so we do not discriminate against people on Medicaid for access to care. But we have chosen not to do that because it fits with the numbers. It fits with the Washington, government-centered management of health care.

I will tell you as a physician, we would be better off--single-payer rationing and all--than what you are doing to so many of these patients in this bill. We would be better off with the government just running it all, rationing it, and saying: Tough, you get to 75 years of age, you can't get your hip fixed; you get cancer, we are not going to give you the latest drugs. We would be better off because now we are going to get the worst of both worlds. We are going to get the rationing through these three panels I talked about. They are going to tell doctors what they can and cannot do. They are going to practice medicine--the very people who have never touched, never had an encounter, never visited with that patient and do not know anything about them--they are going to make a decision.

Mr. President, I would inquire, I think I have 5 minutes.

What is the request of my ranking member?

I think I will finish up in seconds.

Every person in this country should be able to have access. I agree. Nobody should lose their home. Nobody should have to file for bankruptcy because of health care. I agree. That premise we agree on. How we get there is in two totally different ways.

The No. 1 impediment to access is cost. Costs are not going to go down. We know that by all the studies. The health care costs are not going to go down. They are not going to go down per individual and they are not going to go down in total. So we will not have fixed the big problem with health care, which is cost.

We will have worked on access through a government program, but we will not have fixed the real problems. What are the real problems? Fraud is at least 6 percent of the cost of health care. Tort extortion by the trial bar is at least 6 percent of the cost of health care when you count defensive medicine. There is 12 percent where you could lower it tomorrow--12 percent where you could lower the cost of health care tomorrow if, in fact, we would fix the real problems.

No. 3, transparency with insurance companies and transparency with doctors so you know what the cost is, you know what the outcomes are, you know what their track record is, so you can truly make a decision about your care. There is no incentive for that, the incentivization for prevention and management of chronic disease.

I have said this on the floor before, but it bears repeating: The reason we have a primary care doctor shortage in this country today is because of Medicare. The Centers for Medicare & Medicaid Services sets the rates of reimbursement for primary care encounters in Medicare, and everybody else follows it. So you have a disruption, a differential of 300 percent from a family practice doctor and an obstetrician like me to a super-subspecialist. And what do you think the doctors in medical schools are doing? Last year, only 1 in 50 went into primary care. Only 1 in 50 went into primary care.

So let's say we get everybody covered. Who are they going to see? Oh, I know what the answer is. We are going to use physician extenders. So not only are we going to say you are covered, now we are not going to give you an experienced, gray-haired, reasoned, long-term educated physician with 25 or 30 years of experience; we are going to hand you off to somebody who is a nurse or a PA who is good at limited things but does not practice the art of medicine.

So I will wind up with this. I so want to fix health care. I am so sick of the way it is. But I am not near as sick of the way it is as the way it is getting ready to be under this bill. I know my patients are going to get hurt under this bill. My Medicaid patients are going to get hurt under this bill. My Medicare patients are going to get hurt under this bill. And those who are in between--whether it is with insurance with their employer or insurance they are buying on their own or they are paying cash--are going to pay more for their health care because of this bill. That is what I believe is going to be the outcome of this bill. And all you have to do is go look at the history. Talk to Alice Rivlin, the first CBO Director, about the accuracy of CBO in estimating anything when it comes to health care. They have missed it every way. They have only gotten one ``wrong,'' by saying it was going to cost more. For every other one, they said it was going to cost less than it did. So every patient--every patient--in some way or another is going to suffer under this bill. That is what we should be worried about. We should not worry about whether the President wins or we win.

I thank the Presiding Officer for the accommodation of the time, and I yield the floor.

Mr. President, I am going to ask to have printed in the Record a letter dated December 1, 2009, from the insurance commissioner of the State of Oklahoma--she happens to be of your party, the majority's party--outlining the significant problems that she sees for our State if this bill becomes law. This is not a partisan document. This is a document that relates to what is going to happen to Oklahoma.

If I might summarize, very shortly: It will increase premium costs and increase the number of uninsured people in Oklahoma. That is according to our State insurance commissioner, who is of your party. It will decrease the amount of availability of insurance to people who do not have insurance today.

The letter states it will not rein in the cost. In fact, it will increase costs for everybody else in the State of Oklahoma. It will drive up costs and increase the number of uninsured. It will increase the costs for the private plans, negatively impacting medical providers and the health delivery system in Oklahoma, and it will encourage fewer businesses in Oklahoma to offer benefits.

That is a fairly strong indictment from somebody who cares about the people of Oklahoma and what is going to happen in health care.

Mr. President, I ask unanimous consent to have printed in the Record this letter from the State insurance commissioner of Oklahoma.

Mr. President, I yield the floor.

If I might, I ask unanimous consent to have printed in the Record the consolidated audited financial statements of AARP. They are the fifth largest insurance sales company in America.

Mr. President, I thank you. I appreciate it. I sat here and listened to my colleagues to hear their input. I find it extremely peculiar that the only industry for which you would limit their taxes is one that has not struck a deal with the committee. The only one. Pharmacists are going to spend $70 million advertising for this bill. The other industries are putting up additional moneys to advertise for this bill. The only industry that we are going to restrict is the industry that is in opposition to what we are doing. It is interesting.

Senator Cornyn made the point with me a moment ago that we are going to take $450 billion, and we are going to give it to the very industry you are talking about. We are going to take $463 billion from Medicare and give it to the same industry you are now criticizing.

Senator Baucus said--and let me quote--he said: As we tried to work this, it was ``rough justice'' to put this agreement together. This is democracy.

It was done behind closed doors. That is not democracy. It was done behind closed doors. The Senator from Arkansas asked why we have not brought forward something. The Senator from Massachusetts asked. The first bill introduced was the Patients' Choice Act.

I commend to my colleagues a white paper by Thomson Reuters, a very well respected firm, talking about the $600 to $850 billion worth of waste in the health care system today, entitled ``Where Can $700 Billion in Waste Be Cut Annually From the U.S. Healthcare System.''

The reason we are concerned about $465 billion coming out of Medicare, to be paid to the very insurance companies you are going after right now, is because we are not going where the real waste is. The promise of the President was to cut the cost of health care. Right here is where it is. This bill does not touch it.

There is $175 billion a year in fraud in the health insurance industry. You all go after $2 billion of it--$2 billion. There is $175 billion a year in fraud. What is in it? Nothing. We are going to manage to pay a private industry, but only the private industry that will not play along behind the closed door, rough justice of democracy in this country.

When Senator Corker asked the chairman of the Finance Committee, Why are you taking the money from Medicare and using it somewhere else, rather than extending the life of Medicare, he did not answer the question. The fact is, there is a $44 trillion--according to the latest calculation, if you go to the Medicare trustees: $44 trillion--counting what has been borrowed--unfunded liability over the next 75 years for Medicare. We are going to take $\1/2\ trillion out of that program that we all know is going wrong. And I do not doubt the motives of anybody here. I just think we are misdirected. And we are going to take that and spend it on another program. That is where people ought to be concerned.

It is interesting--I will submit another document for the Record. This is

a report from the Congressional Research Service, released December 1, 2009, at my request.

I ask unanimous consent that document be printed in the Record.

Here is what it says. I asked them what percentage of health care today is run through the government. You might be interested to know it is 60 percent. As the Finance chairman responded on why we were fixing it, we are going to create 70 new government programs in this bill--70 new government programs in this bill--and we are fixing the government programs we have now. And we wonder why health care costs are out of control? They are out of control because the government is running 60 percent of it now, and there is no competition for that 60 percent.

Nobody is going to defend outlandish salaries, but it is interesting, we are not going after the outlandish salaries of the companies that are going to spend $80 million to support this bill, the pharmaceutical companies. We are not going to go after the salaries of the people who run the hospitals who, on average, make more than $1 million a year. We are not going to do any of those. Only the ones who say: Wait a minute. Maybe this is not such a good deal.

Mr. President, I commend to my colleagues a document entitled ``Impact Of The Patient Protection And Affordable Care Act On Costs In The Individual And Small-Employer Health Insurance Markets'' from Oliver Wyman and Associates, because what you claim you want to do is going to create 11 million young people who are not going to have insurance, and for those who remain, their insurance is going to cost twice as much.

Mr. President, I thank the chairman for allowing me to respond.

Madam President, I ask unanimous consent that myself and the Senator from North Carolina consume the next hour discussing the health care bill.

Madam President, we have been discussing health care in Washington for the past 8 months rather vigorously. Four years ago I started working on a bill with my colleagues in the Senate and we introduced a bill 2 years ago and modified it this year. It was introduced before the House bill, it was introduced before the Senate bill. It was introduced before the bill we have on the floor at this time. It is called the Patients' Choice Act.

We have heard several times that the Republicans want to stop this. As a practicing physician, I fully recognize the need to significantly reform health care. There is no question. I recognize that. In that bill is a guaranteed issue--no preexisting conditions are allowed in exchanges under our bill. But I also recognize that as we fix health care, some of the things we cannot do are make our fiscal situation worse and also our inefficiencies worse.

Earlier today I referred to research put out and published in October of 2009, which is a white paper on the waste in our health care. This is Robert Kelly, vice president, Health Care Analytics, at Thomson Reuters, a highly esteemed, reputable firm which says that every year between $600 and $850 billion of money is wasted in health care. It is wasted. It doesn't help anybody get well and it doesn't prevent anybody from getting sick.

When you look at the breakdown of where that comes from, it is rather apparent that the largest component of it is unwarranted use. They break that down. What is that? That is me as a physician--I am a practicing physician, delivered thousands of babies, cared for thousands of grandmoms, granddads, kids, set bones, done operations-- old-time, broad-based practice.

But what is this unwarranted use? Madam President, 40 percent of $700 billion is $280 billion a year. They are saying a total of $700 billion, times 10 years in my math, at least from Oklahoma, is $7 trillion.

We have not begun to touch in any of these other bills this unwarranted use, the fraud and abuse--19 percent--that comes to $175 billion a year in fraud. Most of it is not in the private sector, it is in Medicare and Medicaid. That is where most of the fraud is. We have not begun to touch that, we have not attacked it. There is a minimal $2 billion over 10 years of direct fraud elimination in the bill we have on the floor.

Administrative inefficiencies. That is the bureaucratic paperwork that both the hospitals and the doctors spend money on to make sure they maintain compliance with the regulation of medicine--17 percent. That 17 percent comes to somewhere between $100 billion and $150 billion a year that does not help one patient get well. It doesn't prevent one patient from getting sick.

In this unwarranted use happens to be the very thing that none of the bills attack, except our bill, which is the defensive medicine costs in this country. Why would it be important to fix that? Because it is close to $200 billion a year. That is $200 billion of tests that are ordered on patients, on procedures that are done on patients they do not need, because the doctors need to do it to prevent themselves being exposed to unnecessary litigation. That is $200 billion a year, that is $2 trillion over 10 years. Yet we do not address it, not one iota in the bill we have on the floor.

Avoidable care--those are complications. Those are things that we cause. Iatrogenic, they are induced complications. We are not going to be able to do much with that. We could fix this--lack of care coordination with accountable care organizations--by incentivizing outcomes, by grouping in payment for how we pay. But we have not done any of that.

So here is Thomson Reuters that is showing if we want to drive down costs in our health care system, what do we have to do? We have to attack where the waste is. There is nary a gnat's rear end of reduction in these things in the bill that is before us.

The other thing I referred to earlier today was a report by the Congressional Research Service, which was issued December 1, this year, last week. What did they say? The question that was asked of them: What percentage of health care is run or funded by the Federal Government today--or the governments today? The number came back--I have been quoting 61 percent on my back-of-the-envelope calculation. The number came back, as affirmed by Congressional Research Service, that 60 percent of all health care in America is funded through or by your tax dollars funding through a government organization.

The question has to be asked: How well are we doing? Could there be any coordination or connection to the fact that the government is now running 60 percent of the health care, and health care inflation is twice what all the rest of the inflation is? Could there be any connection between the inefficiencies that are in health care and the fact that we have bureaucracies that have themselves in between patients and their providers? I think the answer to that is an astounding yes.

I visited with a cardiovascular surgeon, because I have made this statement on the floor and people have disputed it.

Find me a doctor who has trained in the last 30 years in this country, who spent part of his training at a VA medical center, and ask him or her the following question: If you or your family were sick and you had the choice of where you trained at a VA hospital or any other hospital you trained, would you go to the VA hospital or would you go to one of the private hospitals where you trained? One hundred percent will say no.

Our VA system has markedly improved. I will readily admit, in certain areas, they are better than anybody else, especially prosthetics, especially post-traumatic stress disorder. They are better. But on the vast majority of the issues, they are not. They are run by the government. Look at the Indian Health Service. We have a profound legal treaty obligation to provide health care to Native Americans. Yet Indian health care is abysmal. That is a government-run program. Then look at Medicaid, which we are going to put millions of people in. What happens? In Medicaid, 40 percent of the doctors and 65 percent of the specialists will not see you. But we are going to say: We will give you coverage in a system where you have access to only 60 percent of the doctors. That is not choice. That is relegating you to a system that says you can't get care.

I have talked on this floor about pediatric subspecialties. Because of Medicaid, we have an absolute dearth of pediatric subspecialties because the payment mechanism is so low that nobody will spend the extra time in residency to become a pediatric subspecialist. Whether it is a cardiologist or gastroenterologist or pediatric neurologist, we can't find them. Nobody will go there. The rates for reimbursement are set so low. So physicians graduating from medical school make an economic decision based on the health and well-being of their family to not go into those areas because we have forced them.

What we know is, there are poorer health outcomes in Medicaid. That should not be surprising. Some of the best doctors are not available to Medicaid patients because we will not pay for their expertise. We also pay an extra $1,800 per family, everybody in this country who has insurance, because of the underpayment of Medicare and Medicaid. Finally, with the large tranche of people under this bill who are going into the Medicaid Program, we are going to break the States, if they are not broken already. We are going to cover it for 4 years. For certain States, we will do a whole lot better than that; Louisiana and a few others for which we have made special exceptions. But we are basically going to transfer a load of fiscal responsibility, call it equal, and put that load on the taxpayers of the individual States.

As we look at health care, one of the things I wished to do was to talk about

the problems but also talk about the bill we have before us and make this point. Are we better off with the government running health care or are we better off changing the system in such a way so the patient is put first, the government is put last, and the doctor is a 100- percent advocate for their patient? Which would be the better way? Knowing that we have $7 to $800 billion a year wasted, why would we not design a system that goes after that waste and create the same opportunity for everybody?

When you look at the Patients' Choice Act, which my colleague, Senator Burr, will talk about in a minute, there are some important things. First, let me tell what the CBO says about it. The CBO says it will reduce future budget deficits, relative to protections under current law, by amounts that increase over time--the first 10 years, $70 billion. But what it will do for the States is $1 trillion in savings the first 10 years. It will lead to lower budget deficits. That is what the CBO said. It said it also would reduce spending on health care because it will be more efficient spending. Then, finally, the Federal contribution for Medicaid would grow at a lower rate, lower than health care inflation, which means it is going to save a ton of money for the States.

The bill we have before us creates 70 new government programs. It has 1,696 times that we will write bureaucratic rules and regulations that are going to cause the government to step between the patient and their caregiver. It is estimated, right now, to add somewhere around 20,000 new Federal employees--we are trying to get a handle on that--20,000 new Federal employees to tell you what you will and will not do in your health care. It is going to create at least $5 to $10 billion in new requirements for the Internal Revenue Service just to check on you. That is per year to check on you to make sure you are filling out the forms right. It will create a massive disruption in the insurance market.

Nobody who practices medicine today likes insurance companies. The very fact that we would have our colleagues claim we are defending the process is absurd. What we are defending is allowing the free market, with legitimate regulation, to allocate a scarce resource without putting the patient second. There is a big difference. I can tell you horror stories about insurance companies, but I can tell you worse stories about the Federal Government and the fact that it denies twice as many claims per 10,000 claims as all the other insurance companies.

So when we are talking about access to care, both of the bureaucracies are a nightmare. Yet this bill creates the mother of all bureaucracies, the mother of all new programs.

I will make one last point and yield the floor. We have been down here fixing things that are wrong. We fixed the Preventive Services Task Force. We said it doesn't apply to breast cancer screening. That is what we said. We voted for it. It doesn't apply. Are we going to pass that every time? We didn't get rid of it. We didn't get rid of the Medicare Advisory Commission. We didn't get rid of the Comparative Effectiveness Panel. Every time they make a bad decision, are we going to pass a law and say: You were wrong or are we going to trust the professionals, the professional societies that guide my practice of medicine today or are we going to have a bureaucrat and a bureaucratic system that says what you will get and what you won't? Under the bill we have, you are going to have that. We have taken the hot potato off the floor in terms of breast cancer, in terms of what they said. We said it doesn't apply. We passed something for women's health which I applaud. But what about men's health? What about children, what about prostate screening for men? What about colon screening for men? What about cardiovascular screening for men? We didn't do a thing. Why didn't we? Because we know a larger percentage of the emotional attraction has to do with those things associated with women. So we pounded our chests and passed the Mikulski amendment for preventative care for women, and we ignored the preventative requirements of everybody else. How does that fit with what we should be doing?

It doesn't connect. It is political. It makes good news. It satisfies vocal interest groups. But does it fix the long-term problem?

I yield to my fellow Senator from North Carolina.

Madam President, will the Senator yield for a question?

Does the Senator recall the vote in the HELP Committee when this bill was offered--this bill that allows you to keep whatever you have, if you like it; this bill that gives no tax increases on American families; this bill with no increase in taxes on American business; this bill that lowers everybody's health insurance premium; this bill that covers preexisting conditions, period; this bill that protects seniors' high quality of care and keeps their choices; this bill that increases personal control over health care; this bill that does not do a Medicaid expansion but, instead, puts Medicaid patients into real insurance so they can have the same choice as every other American; this bill that protects physician-patient relationships; and this bill that empowers patients, families, physicians, and providers, but does not empower the government--what was the vote, does the Senator recall?

Exactly right. The difference is, you can either trust people or you can put all your trust in a nanny state, and the nanny state is running 61 percent, 60 percent of our health care today.

I thank the Senator for answering my question.

Madam President, could I inquire of the Chair how much time we have remaining?

Madam President, I want to go back over some of the things in the Patients' Choice Act because people ask me why they have not heard of it, and it is because the press does not want to cover a commonsense bill that does not spend money. The majority does not want to incorporate the ideas because it is not government-centered, it is patient-centered. We have a bill on the Senate floor that is totally government-centered.

But what does the Patients' Choice Act do? Senator Burr alluded to a lot of it. But I want to go into it in a little bit of depth.

What it does it is looks at the five preventable diseases in this country that consume 75 percent of our dollars, five chronic diseases: heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes. They cause two-thirds of the deaths and consume 75 percent of our dollars. The Patients' Choice Act invests in preventing those diseases.

The second thing it does is it creates affordable and accessible health insurance options--not government-run, not government-mandated, but uses the experience of 50 States through exchanges and sets a floor. What is the floor? The floor is the same level of care Members of Congress can get. That is the floor. But you get to choose. Nobody says you have to have this.

Do you realize that 15 million Americans who are going to be forced into Medicaid in this bill will not have any choice? They will just say: You have Medicaid. And they will be denied 60 percent of the doctors in this country.

It eliminates preexisting conditions. It eliminates the ability of an insurance company to drop you if you are sick. You get offered health insurance regardless of your age or regardless of your health. Yet we are saving trillions, and they are spending trillions.

What is the difference? What is the disconnect? It gives you, as Senator Burr talked about, an auto enrollment mechanism. If you choose to be irresponsible, that is fine, but the rest of us should not have to pay for your irresponsibility. So if you do not sign up, you have an automatic enrollment with your tax credit that puts you in a very high deductible plan, so if you have a catastrophic illness, the rest of us do not have to pay for you.

It also allows States to join in pooling arrangements, or regional areas, where they increase their buying power through these exchanges.

Whatever you have today, if you like it, you really can keep it. That is not true in this bill that is coming across the Senate floor. There is an absolutely zero tax increase on American families, and it is not true in this bill on the floor. There is $500 billion worth of tax increases on either families or businesses.

It lowers the cost of health insurance premiums. This one on the floor says, at best, in the large group and medium group market, it is going to be about the same trajectory of twice the inflation rate. But if you are in the individual market, it is going to be 10 to 13 percent higher. Our bill lowers everybody's cost. It protects the seniors' high-quality care and choices today. It doesn't pick winners and losers; it allows patients to pick what is best for them. It increases patients' own personal control over their health care, and it converts Medicaid to a system where no longer are patients in Medicaid discriminated against because what we do is we buy them an insurance system--allow them to buy insurance where nobody will ever know they are a Medicaid patient, so nobody will ever know to deny them, because the patient rate will be equivalent to anybody else in the insurance market. So we give them the same access.

We treat Medicaid as we treat Indian health care: Here is your health care, but it is not as good, so tough it. Here is your health care. We know the outcomes aren't as good. So what. Those aren't Tom Coburn's opinions. Those are published data where we know the outcome in Medicaid isn't as good as any of the other insurance programs or it is not as good as people who are in the cash market even though they pay more.

It protects patients and their caregivers' relationship. Finally, it empowers patients. It empowers mothers to make choices for their children; gives them a broad array of choices. It empowers, but it doesn't empower the Federal Government.

The Federal Government is failing in health care right now. It really isn't my ingenuity that came up with this chart, but since I am around my three daughters and a lot of younger people who work for me on my staff, this is a comparison of the Patients' Choice Act or the act we have here. It is like comparing old Ma Bell to an iPhone.

The Patients' Choice Act is the iPhone.

A little over a decade ago, iPhones or even cell phones in general-- who would have thought they would be so widespread? Apple's iPhone was the fastest growing smartphone of 2008, and its 2008 sales were 2\1/2\ times higher than 2007. Why the increase? Why did iPhone sales take off? What did they do? They are hugely popular because they are user friendly and they allow tons of options and you get a personalized iPhone experience that you control.

So what does an iPhone have to do with health care? Both sides of the political aisle rhetorically agree that

American consumers prefer products that are personalized, that fit their needs, that are affordable, and that are portable. It sounds a lot like an iPhone. As a matter of fact, my colleagues across the aisle are now using the language ``choice and competition'' to try to sell this monstrosity on the American people, the most massive expansion of Federal Government control since Johnson's Great Society.

The problem is that the policies in this bill would discard the iPhone's individual choices and consumer control. But what it would embrace is Ma Bell, the old land line black phone with a rotary dial. That is what we are going to embrace with this bill. We are not going to embrace the iPhone; we are going to embrace being locked to your house with limited choices, limited capability to expand your choices, and limited freedom.

I am happy to.

Absolutely right.

It puts the consumer--i.e, the patient--in charge of their health care rather than the government in charge of their health care.

I don't think there is any question that is going to happen. Actually, it is even going to be worse than that because we have shrunk the differential for young people. If you are a young person, listen to me. The cost of your insurance is going to double under this bill. If you are a young couple or a young individual--and I am talking 40 and under, 24 to 40--your insurance is going to double under this bill. What you are going to do, you are going to do this: You are going to say, I am going to pay the tax rather than coverage for insurance because it is financially much more important for me to do that. And what we know is that between 6 million and 11 million young people are going to cancel their insurance under this bill, according to a report put out by--and I will reference it here--Oliver Wyman and Associates.

What do you think is going to happen?

What is going to happen is the spread--the people who have insurance, if you are over 40, because these young people drop out, your premium is going to go up. So what is available today because of the mix of people who are in the broad group of pools who are insured--we are going to drop out young, healthy people, so that small younger group insurance is going to go up. But because there are going to be 6 million to 11 million fewer of them and the insurance company keeps them in the pot to lower the cost for the older ones, the 65 and above, their premiums are going to go up.

So we are going to have exactly the opposite effect because when you mandate coverage and you force people to buy it with a big government program, people are going to make an economic decision--and the first year of this is $250 is all you have to pay, and it goes up to $750-- they are going to say: Why would I do that? I will buy the insurance when I get sick.

So what we are going to do is totally disrupt--and it may be planned to be that way so we can come back and say: Well, look at the private insurance industry. It is not working. The government needs to take it all over. I don't know that is the case, but the consequences of what this bill is going to do----

Oh, yes, it does. We will have at least 20,000 new Federal Government employees. It will benefit them. It will benefit the bureaucracies. It will give them power to control. It is not a soft control or a light control; it is a heavy control. We will mandate on States bankruptcy through Medicaid--mandate to the States--the mother of all mandates to the States. So it will benefit the Federal Government and the bureaucracy but will have minimal benefit for the patients in this country.

Supposedly.

Well, I wouldn't go quite that far. There is no question that some people who have no coverage today will get Medicaid. But compared to the Patients' Choice Act, they could get a private insurance policy instead of Medicaid. They would get access to all of the physicians, not just 60 percent of them.

And save $2.5 trillion and have the flexibility of choice based on what they need and what they perceive their children or family needs.

So they do increase coverage, but how do they do it? They put you into a substandard plan. They put you into a plan that doesn't give you the same access Members of Congress have. They put 15 million people into that, and they decrease the flexibility and choice for those people, 11 million people, in Medicare, because we know better.

Madam President, if I may inquire how much time we have remaining.

Thank you.

Again, going back to incentive, carrots versus sticks, how is it that we have a shortage of primary care physicians in the country? Why is that? We have put a lot of money into medical schools. The States have put a lot of money into medical schools. We have student loans for physicians who average about $170,000 in debt when they get out of there. How is it that people don't want to be a pediatrician and a general internist or a family practice doctor? Why is that?

The reimbursements, where you can invest 1 additional year in residency and double the income you can make from being a physician.

How did the payment rates get where they are? Who set the payment rates? The Federal Government set the payment rates because 60 percent of the payments to private physicians come from Medicare, Medicaid,

Those are contracted. Those are even lower. So they set them. Private insurance sets all the rates based on what the government does. So the government has created a shortage of primary care which we are going to see just explode as we put other people--the CBO has rightly said, if you add lots of people, you will get some increased utilization, a significant amount. They are not there. They are not there.

So you take somebody in their late fifties, mid- to late fifties or early sixties, who planned on practicing 10 or 15 years, and all of a sudden you say--and we don't in this bill. We had the claim today that this extends the life of Medicare. Well, here is how it does that. It uses the Medicare Advisory Commission to force cuts in Medicare, not fraud necessarily, just cuts. It doesn't pay for the doctor fix, which is $250 billion, and then it cuts Medicare.

So the reason--and I don't have any problem extending the life of Medicare--I think so--but it ought to be all about fraud. It ought to be all about--the vast majority of fraud in health care today is through government programs, not the private sector. The fraud rate in the private sector is less than 1 percent. Here we have $150 billion. We could save $1 trillion over the next 10 years if we had an effective fraud program, which this bill minimally addresses, which our bill aggressively addresses--aggressively addresses. We even have undercover patients, undercover doctors where we create sting operations to put people in jail--not fine them, not ban them from Medicare; we put them in jail if you are stealing from the American people.

There is nothing anywhere close to that in this bill. So, in fact, we are aggressively going after the largest problem of the $800 billion that is wasted every year, which is fraud.

The second largest problem is we need to incentivize the States to fix the tort extortion that is going on in this country that causes people to have tests done on them, not necessarily without any consequence to their health, and money wasted on tests so the doctors can be in a better defensive position.

And it doesn't reform. I have wondered that.

Well, we have protected some through earmarks in this bill--certain States; we have protected some. In some States, if you have Medicare Advantage, you are protected. In other States, if you don't happen to be on that side of the aisle, or you don't need help in your reelection, you don't get that.

If they could afford it--and that is where a large number of Medicare Advantage people will be hurt; most of those people cannot afford to buy a supplemental policy. The fifth largest seller of insurance policies in the country happens to be AARP.

For AARP.

We are fairly cynical, and we don't mean to be. We need to wrap up, if we can. There are two ways of fixing health care in this country. One is, we have the government running it--I make this point. Everybody agrees that in 2017 or 2019, Medicare will go belly up. Medicaid is already belly up. They are all in trouble. They are running deficits. The Census is broke. Social Security is going to be broke. The U.S. Post Office is absolutely broke. Cash for clunkers was broke before we started. The highway trust fund is $18 billion in the red. And we are going to put another 16 percent of health care--76 percent instead of 60--in the hands of the government. Or we can utilize what we know works, which if you incentivize the management of chronic disease and incentivize prevention, incentivize transparency, and you create a way for people to have access, the Patients' Choice Act will insure 94 percent of Americans with a real insurance policy, not Medicaid or Indian health care.

By the way, Native Americans, listen up. Under our bill, if you are due health care, you get a card and you can go anywhere you want and it will be paid for. We need to do that for veterans, too.

The point is there is a choice. We can run a large government option or we can run a small government with 50 States, incentivizing them to do the right and best thing for their citizens, where we will actually lower costs, increase access, and have better care, and we won't destroy the best health care system in the world.

I challenge my colleagues to come down here to the floor and debate me on that, because I guarantee you that in their families I can find somebody who was saved because they lived in this country and, had they not, they would not be alive. It is the best health care system in the world. Why should we destroy that as we try to fix what is wrong in health care in America today?

Let me interrupt my colleague. Here is what the constellations show. Walk with me slowly. If you are 25 years of age or younger today in America--and we go out 20 years--that will be 45 and younger--that is 103 million Americans who will be in that group. Here is what they are each going to owe based on the unfunded liabilities of Medicare, Medicaid, and Social Security: 103 million Americans, 45 years and younger, will each owe $1.119 million. That is what they will be responsible for. They will have to pay the average interest on that, which will be about 6 percent. Before they ever pay the first bit of income taxes, they will have to cover that interest; otherwise, that will grow.

How does that fit a young family 20 years from now? We are talking about tax rates that allow no increased standard of living. As a matter of fact, they are rates that decrease the standard of living by 35 percent. That is the heritage we are creating and what we are going to expand with this health care bill the majority leader has brought to the floor. We are going to steal the future and the opportunity for those 25 years and younger today, because we cannot live and make the hard choices that are necessary, and we think the answer to every problem is more government, rather than more personal responsibility, competition, transparency in a market, and incentivizing people to do the right

thing, rather than punishing them when they do the wrong thing.

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

Mr. President, I ask unanimous consent that Josh Trent of my staff be granted the privilege of the floor for the duration of the debate on H.R. 3590.

Madam President, it is interesting, as a practicing physician who has actually cared for women and nobody so far who has been in on this debate has ever done. I congratulate the Senator from Maryland for her care about prevention because we all know that is key.

The mischaracterization we heard about this bill is astounding. The reason we got in trouble with the Preventive Task Force is because it did something that was inappropriate and did not have the appropriate professional groups on its task force when it made its recommendation on breast cancer screening.

The Murkowski amendment says we will rely on the professional societies to make the determinations of what must be available. We have heard the Senator from Iowa say health insurance will decide that. That is absolutely untrue. Health insurance will not decide it. The professional societies will decide what will be covered, and the insurance companies must cover it under the Murkowski amendment.

The second point is there will not be any objective criteria. The objective criteria doctors practice under today are the guidelines of their professional societies.

Here is the difference between the Murkowski amendment and the Mikulski amendment: The Senator from Maryland relies on the government to make the decision on what will be covered. She refers to the Health Resources and Services Administration. She refers to the Health Resources and Services Administration which has no guidelines whatsoever on women's health care right now, other than prenatal care and childcare. That is the only thing they have.

For whom does HRSA work? HRSA works for the Secretary of Health and Human Services. So the contrast between these two amendments could not be any more clear in terms of do we want to solve the problems we just experienced on mammogram recommendations? We can let the government decide, which got us into this trouble, and they will set the practice guidelines and recommendations for screening or you can let the American College of Obstetricians and Gynecologists or the American College of Surgeons or the American College of Oncologists set and use their guidelines.

The choice is simple: The government can decide what care you get or the people who do the care, the professionals who know what is needed, who write the peer-reviewed articles, who study the literature and make the recommendations for their guidelines.

Every month I get from the American College of Obstetricians and Gynecologists their new guidelines. I try to follow them at every instance. The fact is, the Mikulski amendment says government will decide. That is what it says. The government will decide through HRSA. The Murkowski amendment says it is the best practices known by the physicians who are out there practicing. What is the difference? How does it apply to you as a woman? It applies to you as a woman because the people who know best get to make the recommendations rather than a government bureaucracy. That is the difference.

If you will recall, under the stimulus bill we passed, we have a cost comparative effectiveness panel, which will surely be in the mix associated with the recommendations. If you look at what the task force on preventive recommendations said from a cost standpoint, they were absolutely right. From a patient standpoint, they were absolutely wrong.

The real debate on this bill--the Mikulski amendment is the start of the real debate--is do we have the government decide based on cost or do we have the professional caregivers who know the field decide based on what is best for that patient. That is the difference.

What the Senator from Alaska does, which is necessary, is she says we will rely on the American College of Obstetrics and Gynecology. We will rely on the American College of Surgeons. We will rely on the American College of Oncologists to determine what should be the screening recommendations for patients.

For, you see, what happens with the Mikulski amendment is the government stands between you and your doctor. That is what is coming. That is what will be there.

There is no choice under the Murkowski amendment for an insurance company to have the option either to cover or not to cover. They must. It says ``shall'' do that. So the mischaracterizations on what the Murkowski amendment actually says and does are unfortunate.

I yield the floor.

Mr. President, the chart behind me shows the cuts in Medicare that are in this bill. We have heard all sorts of arguments. I have a few rhetorical questions for my colleagues and my friend, the President of the United States.

There is no question Medicare Advantage costs too much. I have agreed to that with the chairman of the Finance Committee. But you cannot say that coordinated care does not improve the care of seniors, and that is going to be cut. You cannot say that eyeglasses and hearing aids are not going to be cut, and they do improve the care. You cannot say to seniors who cannot afford a supplemental policy, who have Medicare Advantage, they are not going to lose some of their care. They are. In fact, 2.6 million, according to the Congressional Budget Office, are going to lose that very care--not some of it, all of it. They are going to lose that advantage under this legislation. The answer to the question, will this impact seniors care, is yes. We have heard these cuts aren't going to impact anybody or the only people they are going to impact are the insurance companies. Well, I am all for impacting the insurance companies, but I don't want to impact patients negatively.

So we have cuts to Medicare, including hospitals, of $134.7 billion; hospices, $7.7 billion; nursing homes, $14.6 billion; Medicare Advantage, $120 billion; home health agencies, $42.1 billion; and then you say you are not going to do anything to impact the care of seniors. My colleague from Iowa, whom I love, disputed my statement about the fact that the life expectancy is going to go down under this bill. He has never practiced medicine a day in his life. I know what goes on inside hospitals. When you cut $130 billion out of the hospitals, the time you are going to wait for me, the time you wait after you push your call button is going to get extended and the complications from that are going to result in decreased quality of care and shortened life expectancies. There is no question about it.

So we can play the game, but the real thing Americans ought to know is almost $500 billion of spending on Medicare patients today is going to go by the wayside to be spent on a new entitlement, on a brandnew entitlement.

There is no question, to answer my colleague from Idaho, that if it doesn't eliminate the ability, it will deny by delaying the ability. Care delayed is care denied. All you have to do is read all of the tragedies that have gone on in this country for people who have delayed care which has resulted in large complications for that individual.

Would the Senator yield for a moment?

My one criticism of my colleagues in writing this bill is I think there is money we can save in Medicare. It is called waste, fraud, and abuse. A Harvard professor who studies this says there is at least $125 billion a year in fraud. We have had several studies that say it is anywhere from $100 billion to $175 billion a year. There is nothing in this bill to eliminate fraud. What we are doing is we are taking care from seniors instead of taking the money from the fraudulent actors in the health care system.

I thank the Chair.

We are in trouble in Medicare in this Nation. Everybody knows it. We have made promises. The unfunded liability on Medicare is $79 trillion. For us to take $\1/2\ trillion, no matter what the Enron accounting says afterward, the fact is we are going to reduce that; we are going to make that worse. We may not make it worse next year or the year after, but we are going to make it worse. It is going to be worse for seniors, but it is also, as the Senator from Tennessee said, going to be extremely worse for the seniors' kids and grandkids. Not only have we done that, we have raised the taxes in Medicare on a certain group of people and we are going to take that money and not put it in Medicare; we are going to take that money, a Medicare tax, and create a new entitlement.

So the Senator from Florida is absolutely right. If you vote against the McCain motion you are saying you want to cut $\1/2\ trillion out of Medicare and that it will have no effect whatsoever on the care.

I remind the Senator from Florida, there are 1 million people on Medicare Advantage in the State of Florida, 1 million people who are going to lose benefits under this bill. One million people in the State of Florida will lose benefits under this bill.

I think that is entirely possible. I don't know that to be factual as of yet. What I do know is we are going to have 44 million baby boomers in the next 12 years jump into Medicare and we are cutting Medicare. We are going to have 44 million baby boomers jump into Medicare. I am one of them. We are going to cut the amount of available funds from Medicare under this bill.

I have a question. Does 60 Plus sell supplemental insurance policies to seniors?

But AARP does. I wonder why people want seniors off Medicare Advantage.

Mr. President, I thank the Senator. The first comment I have is about relying on what Wall Street analysts say today. They have about this much credibility in this country today. Look at the economic situation we find ourselves in because of what

Wall Street analysts have said. That is the first point I would make.

The second point is that the majority whip yesterday said we should cut Medicare Advantage because of the 14 percent. Senator Dodd just recently went after the Patients' Choice Act because we actually make it be competitively bid without any reduction in benefits. Your bill, for every Medicare Advantage, cuts 50 percent of the benefits out. It cuts the benefits.

The difference is--and I agree with the majority whip--we do need to have the savings in Medicare Advantage, but the way you get that is through competitively bidding it while at the same time maintaining the requirements for the benefits that are offered. There is a big difference in those two. Ours ends up being pure savings to save Medicare. The savings in this bill are to create a new entitlement.

The other point I wish to make is, if you are a senior out there listening and if you are going to be subject to the new increase in Medicare tax, for the first time in history, we are going to take the Medicare tax and not use it for Medicare, we are going to use it for something else under this bill. This one-half of 1 percent is now going to be consumed in something outside of Medicare. So no longer do we have a Medicare tax for the Medicare trust fund. We have a Medicare tax that funds the Medicare trust fund plus other programs.

I say to my colleagues, I think we want a lot of the same things. How we go about it--the Senator from Montana recognized the fact that we are going to increase payments to primary care physicians. Ask yourself the question why only 1 in 50 doctors last year who graduated from medical school is going into primary care. Why do you think that is? Could it be that the government that is setting the payment rates created a maldistribution in remuneration to primary care physicians; therefore, they choose to go where they can make 200 percent more over their lifetime by spending 1 additional year in residency rather than doing primary care?

What this bill does, and what the Senator from Arizona is trying to do by sending this bill back, is to refocus it on the fact that Medicare money ought to be used for Medicare. If, in fact, we are going to slow the growth of Medicare, can we do that without cutting benefits? To slow the growth in this bill for 11 million Americans who now have Medicare Advantage will diminish their benefits. That is out of the $120 billion that is going to come.

You cannot tell a senior who is in a rural area today, who is on the economic lower rungs of the ladder, who uses Medicare Advantage to equalize their care with somebody who can afford a Medicare supplemental policy, you cannot tell them this is not going to decrease their benefits and their care, because it is. And in the bill, it actually states that it is going to decrease their benefits.

Mr. President, will the Senator yield for a minute?

The Senator would probably be interested to know--and, I know, my colleagues on the other side--that the American Medical Association now represents less than 10 percent of the actively practicing physicians in this country. The physicians as a whole in this country are adamantly opposed to this bill. The reason they are opposed to this bill is because you are inserting the government between them and their patient. That is why they are opposed to this bill.

So you have the endorsement of the AMA which represents less than 10 percent of the practicing doctors--actively practicing doctors--in this country because not only will it increase payments, but CPT code revenue is protected. That is the revenue AMA gathers from the payment system that continues to be fostered in this bill, which is their main source of revenue.

Reserving the right to object, I will ask for 2 additional minutes for my side.

How about 1?

One of the questions and one of the promises was: If you have what you have now and you like it, you can keep it. What is happening under this bill for 11 million seniors on Medicare Advantage, that is not going to happen. If they like it, they are not going to be able to keep what they have. You can't deny that. That is the truth.

Medicare Advantage needs to be reformed. There is no question about it. I agree. As the Senator alluded to, in the Patients Choice Act we actually save $160 billion in the Patients' Choice Act, but we don't diminish any of the benefits, and we do that because CMS failed to competitively bid it, because when it was written--and I understand who wrote it--when it was written we didn't make them competitively bid it. You could get the same savings, actually get more savings and not reduce benefits in any amount, if you competitively bid that product. But we have decided we are not going to do that.

The second point I make with my colleagues is the vast majority of people on Medicare Advantage are on the lower bottom economically. They can't afford an AARP supplemental bill. They can't afford to pay an extra $150 or $200 a month. So what happens most of the time with Medicare Advantage is we bring people up to what everybody else in Medicare gets because most people can afford--84 percent of the people in this country can afford to buy a Medicare supplemental policy because Medicare doesn't cover everything.

Your idea to try to save money, I agree with. But cutting the benefits I do not agree with. You are right, Senator Dodd, the basic guaranteed benefits have to be supplied to Medicare Advantage and then the things above that which you get from the supplemental policy, what you can afford to buy, is what these people get. And what you are taking away from poorest of our elderly is the ability to have the same care that people get who can afford to buy a supplemental policy. That is the difference.

I appreciate my chairman for his courtesy in yielding the time.

Mr. President, I wish to pick up where Senator Brown left off. I will describe one of my real patients, but I will not use her real name. I will call her ``Sheila.'' Sheila was 32 years old. She came in with a breast mass. I examined it and thought it was a cyst. I sent her to get an ultrasound, which confirmed a cyst. OK. We did a mammogram to make sure. The mammogram said it looks like a cyst. The standard of care for somebody with a cyst is to watch it expectantly, unless it is painful, because 99 percent of them are benign cysts. I had the good fortune to do a needle drainage on her cyst 3 days after she had her mammogram. There were highly malignant cells within the cyst. She has since died.

The reason I wanted to tell the story about Sheila is because what the Senator from Ohio, in supporting the Mikulski amendment, doesn't recognize is, we don't allow the Preventive Services Task Force to set the rules and guidelines. We do something worse: We let the Secretary of HHS set the guidelines.

The people who ought to be setting the guidelines are not the government; they are the professional societies that know the literature, know the standards of care, know the best practices; and, in fact, the Mikulski amendment doesn't mandate mammograms for women. It leaves it to HRSA, the Health Resources Services Administration, which has no guidelines on it today whatsoever.

So what you are saying with the Mikulski amendment is, we want the government to, once again, decide--all of us are rejecting what the Preventive Services Task Force has said, but instead we are going to shift and pivot and say we will let the HRSA decide what your care should be.

The other aspect of the Mikulski amendment I fully agree with. I don't think there ought to be a copay on any preventive services. I agree 100 percent. But the last place we ought to be making decisions about care and process and procedure is in a government agency that, No. 1, is going to look at cost as much as at preventive effectiveness.

If the truth be known, the Preventive Services Task Force, from a cost standpoint--as a practicing physician, I know how to read what they put out--from a cost standpoint, it is exactly right. From a clinical standpoint, they are exactly wrong, because if you happen to be under 50 and didn't have a screening mammogram and your cancer was missed, to you, they are 100 percent wrong. You see, the government cannot practice medicine effectively. What we are trying to do in this bill throughout is have the government practice medicine, whether it is the comparative effectiveness panel or the Medicare Payment Advisory Commission.

What we have asked is for the government to make decisions.

Let me tell you what that is. That is the government standing between me and my patient. It is denying me the ability to use my knowledge, my training, my 25 years of well-earned gray hair, and combine that with family history, social history, psychological history, where it might be important, and clinical science, and me putting my hand on a patient such as I did Sheila. Most physicians would never have stuck a needle in that cyst, and she would not have lived the 12 years that she lived. She would have lived 1 or 2 years. But she got 12 years of life because clinical judgment wasn't deferred or denied by a government agency.

There is a wonderful member of the British Parliament who happens to be a physician. When we were debating the issue of the comparative effectiveness panel, which will be applied to whatever HRSA or the Secretary does, I asked him: What about the national institute of comparative effectiveness in England? Here is what he said: As a physician, it ruins my relationship with my patient because no longer is my patient 100 percent my concern. Now my patient is 80 percent my concern and the government is 20 percent of my concern. So what I do is I take my eye off my patient 20 percent of the time to make sure I am complying with what the national institute of comparative effectiveness says--even if it is not in my patient's best interest.

When we pass a bill that is going to subterfuge or undermine the advocacy of physicians for their patients, the wonderful health care we have in this country will decline. There are a lot of other things about the bill I don't agree with. But the No. 1 thing, as a practicing physician, that I disagree with is the very fact--the thing I am most opposed to as a practicing physician--I like best practices. I use Vanderbilt in my practice. I like them. They make me more efficient and make me a better doctor. But they are not mandated for me when I see something that in my judgment and in the art of medicine I get to go the other way because I know what is best for my patient.

What we have in this bill is what we passed with the stimulus bill, the comparative effectiveness panel--which is utilized in this bill-- and we have the Medicare Payment Advisory Commission saying you have to cut. Where do we cut? Whose breast cancer screening do we cut next year? When we have the Commission saying we have to, unless we act affirmatively in another way, we are dividing the loyalty of every physician in this country away from their patients. They are no longer a 100-percent advocate for their patients. This is a government- centered bill. It is not a patient-centered bill.

Going back to the Mikulski amendment and what will come with the Murkowski amendment, the Murkowski amendment is far better. It does everything Mikulski does but doesn't divide the loyalty or advocacy of the physician. Here is what it does. The Murkowski amendment says nobody steps between you and your doctor--nobody, not an insurance company, not Medicare or Medicaid. We use as a reference the professional societies in this country who do know best, whether it be for mammograms and the American College of Surgeons, the American College of OB/GYNs, the American College of Oncology, the American Academy of Internal Medicine or the American College of Physicians, which have come to a consensus in terms of what best practices are but

don't mandate what will or will not be paid for when, in fact, the art of medicine is applied to save somebody's life, such as Sheila's.

For you see, if this bill passed, Sheila would have lived 2 years instead of 12. Ten years was really important to her family. She got to see the children I delivered for her grow up. One of them she got to see married.

If we decide the government is going to practice medicine, which is what this bill does--the government steps between the patient and their caregiver, deciding in Washington what we will do--what you will have is good outcomes 80 percent of the time and disasters 20 percent of the time. That is not what we want.

I do not deny that there are plenty of problems in my profession in terms of not being as good as we should be, of not having our eye on the ball some of the time, of making mistakes some of the time. I do not deny that. But what I do embrace is most people who go into the field of medicine go in for exactly the right reason; that is, to help people. It is so ironic to me that we have a bill before us that limits and discourages and takes away the most altruistic of all efforts, which is to do 100 percent the best right thing for your patient.

The reason having HRSA or the Secretary set guidelines is bad is because most patients do not fit the textbook. Here is what the textbook says, but this patient has this condition, this history, and this finding that are different. What we have done in this bill is, multiple times, take the learned judgment of caregivers and say: You will bow to what the Federal Government says; you will bow to what HRSA says; you will bow to what the Secretary of HHS says. Seventy-five times in this bill, there are new programs created; 6,950 times in this bill are requirements for the Secretary to set up new rules and regulations. If you do not think that will put the government between you and your care, you have no understanding of health care in this country and you have no understanding of the problems we face today because of Medicare and Medicaid rules that interrupt and limit the ability for us to care in the best way for our patients.

I am for the prevention aspects of the Mikulski amendment. I think it is a great idea. As a matter of fact, it should not be just about women. It should be about screening for prostate cancer for men as well. It should be about treadmills for people with high cholesterol. It should be about true preventive measures. Why were they not included? Because what we have done under the Mikulski amendment is $892 million over 10 years. We want to do this for one group but we will not do it for the other.

If you think the government will not get in between, let me give three examples right now which violate Federal law today. The Center for Medicare and Medicaid Services today violates Federal law. They ration the following three things:

If, in fact, you are elderly and you have a complication with your colon and you are a high-risk patient to have a perforation if you were to have a colonoscopy--that is when we go in with a fiber optic light to look at the colon--Medicare denies the ability for you to have a CT automated, camera-centered, swallowed-pill colonoscopy, which is available. The technology is proven and is being used outside of Medicare. You cannot have a video colonoscopy by way of a remote- control camera. Why did CMS eliminate that? They eliminated it because it costs too much. So if you are 87 years old and you have a mass in your colon and you cannot have a regular colonoscopy, you cannot even buy this procedure; it is against the law because Medicare forbids it.

No. 2--and this has happened to me numerous times--women with severe osteoporosis--a loss of calcium in their bones at 50 years of age-- diagnosed with a DEXA scan in a screening prevention so they do not get a collapsed vertebra or break a hip, you put them on a medicine. The medicines are expensive, there is no question, but they really do work. Some medicines work for some people; other medicines work for others. Once you do a DEXA scan, under Medicare rules, you cannot do another one for 2 years. So you cannot check to see if the medicine is working after 6 months, to see if you see an improvement in the calcification of a woman's bones, because Medicare said it is too expensive and we are doing too many of them. Rather than go after the fraud in DEXA scans, what they did was ration the care.

Here we have a woman and you have diagnosed her properly. You have started her on the medicine, but you have to wait 2 years. What happens during that period of time if you are given a medicine that is not working effectively? Because it did not work in her case, you have to wait 2 years and her osteoporosis advances and she falls and breaks her hip because Medicare said we were doing too many of them?

Take what CMS did to all the oncologists in this country. They said we are paying too much money for EPOGEN. EPOGEN is an acronym for erythropoietin, which is a chemical that is kicked out by your kidneys to cause you to make red blood cells. When you get chemotherapy for breast cancer or colon cancer, like I have had, sometimes that chemotherapy not only kills your cancer but it kills your blood cells. Because we were using too much EPOGEN, Medicare put out a rule rationing EPOGEN and said: Unless you have a hemoglobin of X amount, you cannot get a shot of EPOGEN, and by the way, you cannot take your own money and buy it either. The doctor will get fined if he gives it to you if you don't meet the guideline. What happens? For 80 percent of the patients, it worked fine. But for those patients who have other comorbid--other conditions, such as congestive heart failure or chronic obstructive pulmonary disease--emphysema--where significant drops in hemoglobin can cause organ failures in other parts of the body, there was no exception made by CMS for a physician to make a judgment and say: This rule should not apply here because this patient is going to end up in the hospital.

My oncologist told me a story of one of his patients who could not get EPOGEN. It ended up that their heart failure was exacerbated because they got anemic from the chemotherapy, ended up on a ventilator in ICU, and died. Why did they die? Because they got heart failure. Why did they get heart failure? Because they got too anemic. Why did they get too anemic? Because Medicare would not allow the doctors to give them the medicine.

What is wrong with the bill, what is wrong with the Mikulski amendment is we rely on government bureaucracies to make the decisions about care rather than the trained, learned, experienced, truly caring caregivers in this country to make those decisions. Instead of going after the fraud in Medicare, which is well in excess of $90 billion a year, we decided we will ration care.

The authors of this bill are going to say: No, that is not true. But when I offered amendments in committee to prohibit rationing of Medicare services--to prohibit it--it was voted down. Every person who voted for moving on this bill voted against the rationing. Why would they do that? Because ultimately the feeling is: We know better. Washington knows better. We know your patients better. We know how to practice medicine better. We are going to take ivory tower doctors who do not have real practices anymore, we are going to take retired researchers, and we are going to tell you how to practice. And we are going to save money by limiting what you can get.

The chairman of the Finance Committee has said we do not truly cut Medicare Advantage, that the services are not reduced. The chairman's own bill, on page 869, subtitle C, part C--I won't go through reading it--reduces Medicare Advantage payments. The differential from $135 to--I will read it to the chairman. The chairman is shaking his head. Let me read it to him. Let me also reference what CBO has said. I will be happy to yield to the chairman if he wants to talk now.

I will be happy to yield for a question.

Page 869, subtitle C, part C.

No required reductions in what?

Reclaiming my time, I ask unanimous consent to have printed in the Record CBO 11/21/2009, which shows an average from $135 down to $51 per month on the average Medicare Advantage beneficiary.

The fact is, if you like what you have, you cannot keep it, for 2.6 million Americans. You can say that is not true. That is what CBO says. Here are their numbers. They sent the report to the chairman.

I will be happy to yield.

Absolutely. I agree with the chairman.

I don't know the actual amount. I agree with the chairman that they are overpaid.

Yes.

I disagree with that.

Here is what I would say. This morning, the claim made by the chairman and Senator Dodd is that Medicare Advantage is not Medicare. Medicare Advantage is Medicare law. It was signed into law. It is a part of Medicare. The chairman would agree with that?

I agree with the chairman. You won't hear that from me. How did we get there? How did we get there? How did we get there, to where they are overpaid? We have an organization called the Center for Medicare and Medicaid Services. They are the ones who let the contract, are they not? They, in fact, are. Twenty-five percent of the overpayment has to be rebated to CMS today; the Senator would agree with that? Seventy-five percent for extra benefits, 25 percent rebate. How did we get to where they are overpaid? Because we have a government-centered organization that is incompetent in terms of how they accomplished the implementation of that bill.

What was said by Senator Dodd this morning--and I confronted him already on it, but it bears repeating--is that the Patients' Choice Act eliminates the dollars without eliminating the services because it mandates competitive bidding with no elimination in services for Medicare Advantage. So if you want to save money, competitively bid rather than go through eight pages of reductions year by year in the payments that go back to Medicare Advantage.

We have this complicated formula that nobody who listens to this debate would understand. I know the chairman understands it because he helped write it. But the fact is 2.6 million Americans, according to CBO, will see a significant change in their Medicare benefits. Medicare Advantage is Medicare Part C. We have had a kind of a differential made that it isn't really Medicare. It is Medicare. And 20 percent of the people in this country who are on Medicare are on Medicare Part C-- Medicare Advantage--and they like it. And why do they like it? Because most of them don't have enough money to buy a supplemental Medicare policy to cover the costs that are associated with deductibles and copays and outliers. So I agree with the chairman that Medicare Advantage is overpaid, but I disagree with the way you are going about getting there.

I also disagree with taking any of the money that is now being spent on Medicare Part C and creating another program. I think all that money ought to be put back into the longevity of Medicare.

In case you don't understand how impactful that is, we now owe, in the next 75 years--actually, we don't owe it, because none of the Senators sitting here will be around. Our kids are going to get to pay back $44 trillion in money for Medicare we will have spent, that we allowed to grow, in fraud, close to $100 billion a year and then did nothing about it. This bill does essentially nothing about that $100 billion a year, or $1 trillion every 10 years. If we were to eliminate that--which this bill does not--we would markedly extend the life and lower the debt that is going to come to our children.

That leads me to the other important aspect of the health care debate. We know when you take out the funny accounting--the Enron accounting--in this bill, and you match up revenues with expenses, you are talking about a $2.5 trillion bill. The chairman of the

Finance Committee readily admits he has it paid for, and CBO says you have it paid for. But how does he pay for it? He pays for it with the 2.6 million people who like what they have today and who are going to lose what they have today. He pays for it by raising Medicare taxes. Then the Medicare taxes he raises he doesn't spend on Medicare, he spends that on a new entitlement program. Think about what we are doing. Is there a better way to accomplish what we are doing?

I thank the chairman for indulging me and allowing me to continue this long. I will wind up with a couple of statements and then share the floor with him.

You know, after practicing medicine for 25 years, I know we have a lot of problems in health care, and I appreciate the efforts of the chairman of the Finance Committee to try to find a solution for them. It is not a bipartisan solution, but it is a solution. And it is a solution that grows the government. It puts the government in charge of health care and creates blind bureaucracies that step between you and your doctor. That is one way of doing it. But wouldn't a better way be to do the following: Let's incentivize people to do the right thing, rather than building bureaucracies and mandating how they will do it. Wouldn't it be better to incentivize tort reform in the States? Wouldn't it be better to incentivize physicians based on outcomes? Wouldn't it be better to incentivize good behavior by medical supply companies, DME, drug companies, hospitals, physicians, through accountable care organizations, through transparency for both quality and price?

We don't have any of that in here. What we have is a government- centered bureaucracy that, according to CBO figures, will add 25,000 Federal employees to implement this program--25,000. If you call the Federal Government, how long does it take you now to get an answer? Yet we are going to add 25,000 employees just in health care. That is an extrapolation of the amount of agencies, dividing what CBO says per agency and per cost they will come up with. Wouldn't it be better to fix the things that are broken, rather than to try to fix all of health care?

I heard one of my colleagues today say on the floor, and I think it is true, that people in America are upset with us, and I think rightly so. I apologize to the American people for my arrogance. I apologize to the American people for the arrogance of this bill; the thinking that we got it right; that we can fix it in Washington; that we don't have to listen to the people out there; that we don't have to listen to the people who are actually experiencing the consequences of what we are going to do. I apologize for the arrogance of saying we can create a $2.5 trillion program and that we know best. Well, you know what, we don't know what is best.

As Senator Alexander has said so many times, what needs to happen is we need to start over. We need to protect the best of American medicine. And what is the best? Well, if you get sick anywhere in the world, this is the best place in the world to get sick, whether you have insurance or not. If you have heart disease or atherosclerotic disease, this is the best place in the world. It costs too much, there is no question, but it is the best place. If you have cancer, you are one-third more likely to live and be cured of that cancer living in this country than anywhere else in the world--for any cancer. It just costs too much.

This bill doesn't address the true causes of the cost. What are the true causes of the cost? Well, No. 1, we know Medicare and Medicaid underpay and so we get a cost shift that is $1,700 per year per family in this country. So you get to pay three taxes in this country on health care: You pay your regular income tax, which goes to pay for Medicaid, and it also now starting to pay for Medicare as well; you have to pay 1.45 percent, plus your employer gets to pay 1.45 percent of every dollar you earn for Medicare; and then your health insurance costs $1,700 more per year because Medicaid and Medicare don't compensate for the actual cost of the care because of the government- centered role that is played in terms of the mandates, the rules, and regulations.

We have a tort system in this country that costs upward of $200 billion in waste a year, which is 8 percent of the cost. Ninety percent of all cases are settled with no wrong found at all on the part of caregivers, and of the remaining 10 percent only 3 percent find anything wrong. Of 97 percent of all the cases, only 10 percent go to trial, and 73 percent of that 10 percent are found in favor of the providers. So we spend all this money practicing defensive medicine and there is not one thing in this bill to fix that problem. That is 8 percent.

Take your health care premium, or your percentage of your health care premium, and apply 8 percent, and that is going down the drain because I am ordering tests you don't need but I need to protect myself in case somebody tries to extort money from me with a lawsuit that I know is going to get thrown out, but I have to have it there to prove it. And then we have inefficiencies.

Ultimately, what we need to do is to protect what is good, incentivize the correct behavior in what is wrong, and go after the fraud in health care with a vengeance--put doctors in jail, hospital administrators in jail. Don't slap them with a fine and ban them from Medicare. Put them in jail. The people who are stealing our grandkids' money, up to $100 billion a year, need to go to jail. We play pay and chase. We pay everybody and then we try to figure out whether they deserve to get paid. Nobody else does that, but the government does, and that is who we are getting ready to put in charge of another $2.5 trillion worth of health care?

One of the reasons health care is in trouble in this country is that 61 percent of all the health care is run through the government today. Look at TRICARE for our military, look at VA care, look at Indian health care, at SCHIP and Medicaid. There is an estimate of $15 billion a year in fraud in New York City alone on Medicaid. That is one estimate, per year, in one city on Medicaid. And then Medicare. And we are going to say those are running so good that we ought to move another $2.5 trillion, or 15 percent of health care, to where we are at 76 percent of all health care is run by the government? I reject that out of hand until we can demonstrate we are good at what we do.

What we ought to be doing is turning it back. The private sector isn't the answer to everything. I agree with that. I can't stand 80 percent of the insurance bureaucrats I deal with. But at least I have a fighting chance, because they will call me back when I need to do something for a patient. I never get a call back from Medicare. They do not call me back. The State doesn't call me back on Medicaid when I need to do something. So I go on and do it and find somebody else to pay for it. That is the kind of system we have today.

Think about the mothers in this country in a Medicaid system where 40 percent of the primary care doctors in this country won't see their children. That is Medicaid. That is realistic Medicaid today in our country. So they have a sick kid, but they can't get in to a doctor, even though they have insurance. They have Medicaid, but they can't get in. Why can't they get in? Because only 1 in 50 doctors last year who graduated from medical school goes into primary care. We have created an abrupt shortage in primary care. And, No. 2, the payment is not enough to pay for the overhead to see the child. So you have a weepy woman who is worried about her sick kid, and care is delayed if you can't get in. It doesn't matter if you have Medicaid if you can't be seen. So what happens? She goes to the emergency room. What happens in the emergency room? We spend three or four times as much as we should, because that is an emergency department. The doctor has no knowledge of the child or the mother. He doesn't want to get sued, so we have a 40- percent defensive medicine cost in the emergency room.

The answer is not more government health care. The answer is creating the incentives for people to do the right thing. The only way we get things under control in health care in this country and the only way we create access for people in this country is to decrease the cost of health care. This bill doesn't decrease the cost of health care. If we want to make sure we do what is best for American medicine while we fix what is wrong, we will do it one significant part at a time. I can't imagine dealing with thousands, tens of thousands of more bureaucrats in

health care, and I can't imagine the impact it is going to have between me and my patients. It is going to severely impact them. Do I want everybody in this country to have available care? Yes; 15 percent of my practice was gratis, for people who had no care, who had no money. That is true with a lot of physicians out there in this country. It is true with a lot of labs. It is true with a lot of hospitals. It is true with a lot of the providers in this country. They are caring people.

We are going to tie them up. We are going to put regulations and ropes around them. We are going to mandate rules and regulations, and we, in our arrogant wisdom, are going to tell Americans how they are going to get their health care. I certainly hope not. But I am not thinking about me. I am thinking about our kids and our grandkids.

I will end with one last comment. Thomson-Reuters, in a study put out October 9 of this year--it is a very well-respected firm--their estimate of the $2.4 trillion that we spend on health care per year in this country is that between $600 and $850 billion of it is pure waste. Defensive medicine costs and malpractice is between $250 billion to $325 billion by their estimate. Not one thing in this bill to address that--not one thing.

Fraud, there is between $125 and $175 billion per year--insignificant in this bill, $2 billion to $3 billion.

Administrative inefficiency, 17 percent--between $100 and $150 billion wasted on paperwork in health care every year.

Provider errors--that is me--between $75 and $100 billion; that is either wrong diagnosis or failure to treat appropriately. It is the smallest of all.

What are we doing? We are going to tell the providers--the hospitals, the medical device companies, the drug companies, the doctors, the radiologists, the labs, the physical therapists--we are going to tell them how to do it. That is not where the problem is.

My hope is that the American people will come to their senses and say: Wait a minute. Slow down. Stop. Fix the important things. Fix the worst thing first, the next thing second, the next thing third, the next thing fourth. The unintended consequences of this bill are going to be unbelievable. Nobody is smart enough to figure all this out-- nobody. Nobody on my staff, nobody on the Finance Committee, nobody in Majority Leader Reid's office can predict all the unintended consequences that are going to come about because of this bill.

The chairman has been awfully patient, and I see my colleague here to offer an amendment. With that, I yield the floor.

Madam President, how much time remains on the Republican side?

Madam President, I ask unanimous consent to consume that 3 minutes and the other 15 minutes allotted to our side on the executive nomination, and when that 18 minutes is up, the remainder be followed by the time on the Democratic side and the nomination be reported.

Madam President, I wished to spend a few minutes on this.

As a physician who cared for Medicare patients for 25 years, I cannot tell you how worried I am about what this bill is going to do to my senior patients. When Medicare was first written, two things were put into the law--very straightforward, very direct. Let me read them to you, for a minute. I hope Americans listen to this. Here is what the law is. CMS is breaking the law today and, with the new Medicare Commission, they are going to break it even further under this bill.

Section 1801 says this:

Nothing in this title shall be construed to authorize any

Federal officer or employee to exercise any supervision or

control over the practice of medicine or the manner in which

medical services are provided, or over the selection, tenure,

or compensation of any officer or employee of any

institution, agency, or person providing health services; or

to exercise any supervision or control over the

administration or operation of any such institution, agency,

or person.

That says that the Federal Government cannot practice medicine. That is what it says.

Section 1802 says this--and this is where it is important for my Medicare patients and everyone out there:

Any individual entitled to insurance benefits under this

title may obtain health services from any institution,

agency, or person qualified to participate under this title

if such institution, agency, or person undertakes to provide

him such services.

Well, what we have in this bill is the gutting of those two foundational principles of Medicare. The first is the Medicare Advisory Commission is going to tell you what you can and cannot have. Here is what we are going to see: You will choose what I tell you to choose if you are a Medicare patient.

Not only do we have almost $500 billion in cuts to Medicare, under the auspices that we have to control entitlement spending; not only are we taking away plans from people who are very satisfied with what they have today, but we have enhanced, and will enhance, the ability of the Federal Government to practice medicine.

My colleagues on the other side of the aisle, who have never practiced medicine, who know the legalese but don't know the consequences of right now the rationing of Medicare on drugs such as Epigen and Neupogen--you see, Medicare has decided when oncologists can use those drugs. They have taken a

blanket position, although they have released it somewhat. But what it says is this--I will give you a patient who has breast cancer. She is 67 years old. She is being treated for breast cancer. She becomes anemic and neutropenic. That means her white blood cell count, her ability to fight infection goes down.

We have wonderful drugs that raise the white blood cell count and raise the red blood cell count. But Medicare, in its obvious wisdom of practicing medicine, has told the oncologists when they can and cannot use it. That is fine for 75 percent of the patients, but it totally ignores the other 25 percent of the patients who happen to have complicating factors, such as congestive heart failure or if they become anemic under breast cancer chemotherapy and have congestive heart failure as well. The government says you cannot have erythropoietin at this level of hemoglobin regardless of whether you have congestive heart failure.

What happens is the practice of medicine out of Washington or Maryland, more specifically, determines who can and cannot have a drug; in this case, erythropoietin.

What is the consequence of that? The consequence is that the patient did not die of breast cancer; she died of congestive heart failure that could have easily been treated had we not had medicine practiced by CMS denying the ability of the physician to give the patient exactly what she needed when she needed it.

We are starting down that road with this bill--aggressively starting down that road--because the Medicare Payment Advisory Commission, combined with the Comparative Effectiveness Panel will not look at complications and will not look at secondary diseases. They will look at the average.

I want to tell my colleagues, when you are sitting in an office with your doctor, you are not average. You are you, and you are a specific individual with a set of factors that nobody else has. The judgment in the practice of medicine cannot be done by an insurance company or CMS at a distance without them having a hand on the patient. They never have their hand on a patient.

The whole art of medicine, which is 40 percent of getting people well, is the knowledge and training and experience and gray hair that comes with looking at the total patient, being one on one, not having the government between the doctor and their treatment of a patient.

What this bill does--this bill is a lie one of two ways. One, it says we are going to take this money out of Medicare and you are not going to notice any difference. That cannot be true. If we take $500 billion or $400 billion-plus out of Medicare, millions of seniors are going to notice a difference in their health care and what they get under Medicare. If we say that is not true, then the only way that is not true is the game that is being played on the financing of this program; that is to say, we are going to cut this money out of Medicare and then with a wink and a nod know we are never going to do it.

The majority leader said yesterday there is nothing more important in this Nation right now than passing health care reform. I differ with that statement. I think 10.2 percent unemployment is a whole lot more important, and finding those people jobs, than passing health care reform. I think a $12 trillion debt is more important to address than fixing health care right now. I think the fact that we have $350 billion worth of waste, fraud, and duplication in the Federal Government every year, and we are not addressing it, is more important than fixing health care right now. I think the fact that our economy is still on its back and people are continuing to lose jobs is more important than fixing health care right now.

I understand the political dynamics, but I also understand very well with my quarter of a century of practicing medicine that what this bill is going to do is destroy the best health care system in the world, and it is going to undermine the security of every senior in this country because what starts as a small couple of things, such as Neupogen and Epogen or like when you can have bone densitometry and whether your osteoporosis can truly be evaluated, CMS has already said how much you can do that, whether your bones are falling apart or not. It is the start of the government practicing medicine.

It is the beginning of our seniors having the government step in between them and their physician in terms of the physician wanting to do what is best for that senior and the government saying: No, I will tell you what you are going to have. I will tell you what you will have.

Thomas Jefferson taught us a lot. He predicted we would have ``future happiness for us if we can prevent the government from wasting the labors of the people under the pretense of taking care of them.''

I want to see a lot of things changed in health care. I want to see true competition in the insurance industry. I want to make sure nobody loses their insurance because they get sick. I want to make sure everybody can get insurance if they are sick. I do not disagree with the basic premise. What I disagree with is moving $2.5 trillion more under government control, which will raise costs ultimately in the health care sector. If it does not raise costs and we are truly going to take this money from Medicare, what it is going to do to our seniors, I have a message for you: You are going to die soon, and they are going to say that is not true, that it is not true.

When you restrict the ability of the primary caregivers in this country to do what is best for their senior patients, what you are doing is limiting their life expectancy. We are saying CMS, the Medicare Payment Advisory Commission, and the Comparative Effectiveness Panel will tell the doctors what they can and cannot do, ignoring the 20 percent of the people for whom that is exactly the wrong prescription. So for 20 percent of our seniors, this bill is going to be a disaster, but it is going to save money because you are not going to be around for us to spend any money on you because the government will have already told us what the treatment plan will be for you. We will decide in Washington through the Center for Medicare and Medicaid Services what you will receive.

They will dispute that, but the people who are going to be disputing that are lawyers; they are not doctors. They have never laid a hand on a patient. They have never put their hand forward on a Medicare patient knowing the consequences of the total patient, the background, the medical history, the sociologic factors that fit, the family dynamics, the past medical history, the family history, and the present state of mind of that patient.

Even more important, what this bill is going to do is divide the loyalty of your doctor away from you. When you go to the doctor today, most of the time that doctor's No. 1 interest is in you and your well- being. When you have this Medicare Payment Advisory Commission and you have this Comparative Effectiveness Panel, what that does is that causes the physician--he or she--to take their eyes off of you. Now they are going to put their eyes on what the government says because the consequences of not doing what the government says will ultimately result in some type of sanction.

Do we want physicians to be patient-centered and focused on their patients or do we want physicians to have their eye on the government and half of an eye on the patient? Which do you think is going to give us the best care? Which do you think is going to give us the greatest quality of life? What is going to give us the greatest longevity with the greatest quality of life? Is it the government practicing medicine, or is it the trust that has been developed through years between a patient and a doctor to do what is in the best, long-term interest of that patient?

I cannot tell you the number of people who die from the CMS regulations on Epogen for oncologists. But there were hundreds-- hundreds--because Medicare never looked at the patient; they looked at dollars.

As we go forward in this debate, what I want seniors in America to know--and I am fast approaching Medicare age; I am 3 years from it--I want them to know the key thing they are going to lose in this bill is the loyalty and primacy of their physician thinking about them. We are going to divide that loyalty to where the physician is going to be looking at the government. If you think that is not true, just look at what has happened so far when CMS

has decided to start practicing medicine.

In the HELP Committee, I offered an amendment to change the language so there would be absolutely a prohibition on rationing care and directing the care from Washington. It was rejected out of hand-- rejected out of hand. Not one of my colleagues on the other side of the aisle voted to prohibit rationing of health care.

Why would they do that? Because the ultimate intention through the Comparative Effectiveness Panel is to ration care. It is to ration the care. It is to limit the amount of dollars we spend and never look at the individual patient.

If we think about the Medicare cuts in this bill, we are going to take $135 billion out of the hospitals. Do you think seniors will ever notice that? I do. I think when you ring your button and you are hurting and you need pain medicines or you need to go to the bathroom, the time it takes for somebody to get there will not be sufficient. What will happen is you will wait. You will have a complication. If you have acute shortness of breath and press the button, the available nurses will not be there. There will be a consequence to cutting $135 billion from payments to hospitals in this country.

We are going to take $120 billion out of the seniors--the one in five seniors who now have Medicare Advantage. I agree, it is more expensive than Medicare. It needs to have some cost containment through competitive bidding, but we should not be decreasing the services, which is exactly what is going to happen. If you are a senior on Medicare Advantage, you are going to lose benefits you now have. You are going to lose them.

One of the ideas of Medicare Advantage was preventive services. One of the things that improved the care in rural America was Medicare Advantage. Yet we are going to take that away. The vast majority of the benefits we are going to cut in half.

We are going to take $15 billion from nursing homes. That may or may not be appropriate, but the way to do that is through a competitive experience based on quality and outcome rather than some green-eyeshade staffer saying we can take $15 billion out of Medicare from payments to nursing homes.

One little secret that is not in this bill, that has not been addressed in this bill, is the estimate by a Harvard researcher that there is $120 billion to $150 billion a year in fraud in Medicare alone. HHS admits to $90 billion. We know it is well over $100 billion a year. Cleaning up the fraud in Medicare would pay for a lot of health care for a lot of folks in this country. There is $2 billion in this whole bill to clean up the fraud.

Why would we not fix that first? Why would we take money from Medicare to create a new program when in fact we are wasting 10 to 15 percent?

I will close with this remark. If you are a senior and you are on Medicare, you better be afraid of this bill. I don't come to the floor and say that very often, but your health care is totally dependent, in terms of being decreased by this bill.

I yield the floor.

There needs to be some clarification. Medicare doesn't cover everything. Eighty-four percent of all

Medicare patients have to buy a supplemental policy now. Do you know what Medicare Advantage is about? Who set the prices on Medicare Advantage? The government set the prices on Medicare Advantage. The very same people you want to run it now created a 14-percent premium. The insurance industry didn't set the prices. The Center for Medicare and Medicaid Services set the prices. The government is responsible for that differential.

Why is Medicare Advantage important? Because the vast majority of the people in my State and every State who have Medicare Advantage can't afford to buy a supplemental policy to make them whole on Medicare, because Medicare won't cover it. So Medicare Advantage for 89,000 Oklahomans is the only way they get equality with the rest of their peer group who can afford to buy a supplemental policy.

Now we are going to take that ability away from poor seniors in Oklahoma, Arizona, Iowa, and Illinois, and we are going to say: You don't get what everybody else has because you are economically disadvantaged. So we are going to give you substandard care, and we are going to take more of your income. Medicare Advantage offers the things you get with a supplemental policy when you can't afford to buy a supplemental policy. The very idea of saying we are going to take that away, when you are taking that away from the cheapest program we have in terms of performance, because what Medicare Advantage does, which their bill and this bill purports to do, is recommends and encourages and incentivizes prevention as the Senator from Iowa wants to do for everybody. It incentivizes it. It doesn't cost to have a prevention exam under Medicare Advantage. There is no out-of-pocket cost for our seniors who are poor who happen to have the benefit of Medicare Advantage. You are going to take that away. You are going to destroy it for 11 million seniors, the ability to get a preclearance, a screening exam, without them having to spend money on it.

Is there a way to get money out of Medicare? Yes, there is $100 billion worth of fraud a year in it. According to Harvard, there is $150 billion worth of fraud a year in Medicare. There is $2 billion worth of fraud.

I want to address something else the Senator----

Mr. President, I would answer my colleague by saying this bill is a government-centered approach, not a patient-centered approach. It is the very reason we are in the trouble we are in today. We have had the government making decisions rather than the patients and the physicians. It will, in fact, lessen the care for seniors.

I gave a speech earlier this morning on the floor that if you are a senior, you should be worried. Because the Medicare Advisory Commission and the cost comparative effectiveness commission will now decide ultimately what you get. We have an amendment on the floor, which in many ways I support but I would like to modify, about reinstituting what should be the standard for mammography for women. How did we get there? We have a commission that looks at cost and not patients. From a cost standpoint, the task force on screening is absolutely right. But from the patient's standpoint, it is absolutely wrong. How do we decide the difference? Do we make the difference based on what something costs or do we make it on what my wife, who will soon be a Medicare patient, receives? The question is, will the cuts that are manifested by this bill impact seniors' care? As somebody who has practiced medicine for 25 years and cared for seniors for longer than that, I will tell you undoubtedly they will have delay, denied care, and 80 percent of them will be fine. But 20 percent of the seniors in this country will be markedly hurt by this bill because a bureaucracy looking at numbers, not patients, never putting their hand on the patient, will make a decision about what is good for them and what is not.

Everything we know about medicine is that is exactly the wrong way to practice it. Every patient is different. Every patient's family history is different. When we talk about taking $120 billion out of the Medicare Advantage Program, what we are talking about is decreasing access to some of the most important screening capabilities that many of these people have and making them unaffordable because they cannot afford a supplemental Medicare policy. They cannot accomplish it.

I want to address one other question. The majority whip said the Republicans have not had a bill. During the markup in the HELP Committee, I went through point by point the Patients' Choice Act. The Patients' Choice Act puts patients and doctors in charge, not the government in charge. The Patients' Choice Act neutralizes the tax effect to make everybody treated the same in this country, as far as the IRS is concerned.

Right now, if you get insurance through your insurance company, you get $2,700 worth of tax benefits. If you do not, you get $100. That is really fair. That is one of the reasons why people who do not get insurance through their employer cannot afford health insurance. It is because we do not give them the same tax benefit. It would give a tax cut to 95 percent of Americans, plus help them buy their care.

The Patients' Choice Act solves the liability problem by incentivizing States to have reforms in terms of the tort problem we have, where we know the cost is at least 6 to 7 percent more that we have spent on health care than we would if we had a realistic tort system.

Finally, we go after insurance companies because we do what is called risk readjustment. If you are dumping patients or cherry-picking--guess what--you have to pay extra; you have to pay to the very insurance companies that are covering those sick people. So we change the incentive to where an insurance company is incentivized to care for somebody rather than to dump them.

I was an advocate, when I was in the House, for the Patients' Bill of Rights.

I was defeated at every turn, trying to make this. To say we did not come with a bill, on a party-line vote in the HELP Committee 13 voted against a commonsense bill that did not increase taxes, did not increase premiums, covered more people than this bill will cover by 4 million, putting everybody in Medicaid on a private insurance policy so no longer are they discriminated against by the doctors who will not take Medicaid, taking the Medicaid stamp off their forehead and giving them the same access to health care we have.

I am. I would tell the Senator, again--how are we where we are? How are we where we are, when we are going to take a program that is working--granted, I think Medicare Advantage could be decreased through true competitive bidding. But CMS did not do that. We could bring the costs down and still have the same benefits. But this bill cuts the benefits in half, the extra benefits that Medicare patients have by being signed up on Medicare Advantage that everybody has who can afford a supplemental policy.

I want to address one other thing, if the Senator would allow me. The majority whip said: Don't we want to get rid of conflicts of interest? Yes. But his argument was specious because the price is set for an X- ray or a mammogram or a CT or a blood test. They are set by Medicare now. There is no differential in the price other than what Medicare says the differential will be. There is no arbitrariness. The government sets the price for every Medicare test out there by region. So there is no way to game it, as the Senator from Illinois said it was gamed. The best reason to have a lab in a doctor's office is so you do not have to wait and come back for another visit to the doctor who charges Medicare another $60 because you get the answer right then. We want to eliminate that. So what will we do? There is no cost savings in that. There is a cost increase because now, instead of giving an answer to the patient, the patient is going to wait as they send it off to the lab, and have them come back in.

Well, if you take $100 billion a year--and that is not an exaggeration; even HHS, this last week, said their improper payments were $92 billion; the Inspector General and the GAO both say it is higher than that; that is on Medicare alone--if we just captured $70 billion of that.

How do you do that? Do you know how Medicare pays down? They pay and then chase. So you submit an invoice. They do not know if it is accurate. They pay it, and then they go try to get the money back afterwards.

How about precertification of a payment, as everybody else does that has anything to do with the volume that Medicare has? The other way you do it is with undercover patients, where you put people actively defrauding Medicare in jail. Less than $2 billion in this whole bill goes after fraud. That is 2 percent of the fraud per year. We could cover everybody in the country or extend the life of Medicare 20 years by eliminating the fraud that is in Medicare today. What are we going to do? We are not. We are going to create more government programs and more agencies that are going to be designed to be defrauded. So, therefore, the fraud is going to go up, not down. The fraud is going to go up, not down.

We are also going to limit the availability of prevention to seniors. I have read the prevention text in the bill. There are parts of it I absolutely agree with. We know if we manage prevention and we manage chronic diseases, we are going to save a lot of money. But we are not going to save any of it by building jungle gyms and sidewalks. What we have to do is incentivize people, both physicians and patients, to get in the preventive mode. We need accountable care organizations.

There are lots of things we can do. There are lots of things we can agree on. I know the Senator from Iowa and I agree on a lot on the prevention, but we ought to be saving that money, and we ought to eliminate the fraud. If we did nothing in this body except eliminate the fraud in Medicare, think what we would have done, think what we would have done for the kids who follow us.

Mr. President, $447 billion spent on Medicare; $100 billion in fraud. Wheelchairs that have been billed out so many times they have collected $5 million on them, doctors who submit false invoices, suppliers who submit invoices for people who are deceased. And we try to go get that after the fact? There are lots of things we could do. This bill is short on that. You all recognize it is short on it. It is the biggest savings out there. The reason there is not more in it is because CBO will not score it because we have never demonstrated that capability.

One final point. This bill only scores the way CBO scores because it says you intend to do what no Congress has ever done. It says you intend to cut Medicare $460 billion to $480 billion. If you intend to cut Medicare, the American people ought to know where you are going to do it, how it is going to affect them. But if you are just doing it for a

scoring point, the young people in this country ought to know that too. Because where you say you are claiming $460 billion, you are adding to the deficit if, in fact, we do not cut Medicare that much. And is it fair to the Medicare Advantage patients, who are poor--who do not qualify for dual coverage with Medicaid, who cannot afford a supplemental policy--is it fair to take away the benefits they have today that we have given them--and it was not priced by the insurance industry; it was priced by CMS--and say because CMS, the government agency, did not price it, we are going to take away half of your benefits? It is not fair. It is not right. If there is anything immoral, that is immoral.

With that, I yield the floor.

Mr. President, I thank Senator Corker.

I have had the distinct pleasure of delivering over 2,500 babies for Medicaid insurance and taking care of their children. These are wonderful folks. I didn't do any differential between Medicaid and private insurance in my practice, but most of my colleagues did.

The heartbreaking part about Medicaid is that when you have a sick child who needs a specialist, you cannot get one. You just cannot get one. You say: Why can't you? Do they not care? Yes, they care. But you know what. Because of the Medicaid reimbursement for pediatric subspecialities--pediatric cardiologists, pediatric oncologists, pediatric hematologists--there are not any.

We only have two pediatric cardiologists in the city of Tulsa serving 1.9 million people. Try to get an appointment for a Medicaid patient there. I can hardly get a regular one. How did that happen? The reason we have a shortage of pediatric subspecialities is directly related to the Medicaid system in this country because the reimbursement is so low that you cannot afford to have a high percentage of Medicaid patients in your practice and still pay your bills.

So what consequently has happened is doctors do not go into pediatrics, and then they do not go into the subspecialities of pediatrics. So I end up having 8-month-old children seen by adult cardiologists or adult hematologists because there is no available doctor to see them because we have created a system through the substandard reimbursement of Medicaid that has directed people coming out of medical school away from that speciality.

As a matter of fact, last year, if you take all the medical students who graduated from medical college, whether it is osteopaths or allopaths, M.D.s or D.O.s, 1 in 50 went into primary care. That is general internal medicine, family practice, or pediatrics, only 1 in 50.

We have 50 million baby boomers going to hit Medicare in the next 7\1/2\ years, and we are not going to have the primary care doctors there to take care of them. The reason is because through government programs, we have incentivized doctors not to do primary care. Consequently, we don't get there.

The other point I will tell you is that if you look at perinatal mortality rates in our population across the country, it is, No. 1, directly related more to poverty than it is to anything else. But the second most important factor is that if you are in Medicaid, you are twice as likely to have a perinatal mortality event--in other words, your child dies after childbirth--than if you are in private insurance. It doesn't matter what your culture is. If you are poor, but you have private insurance, the likelihood your baby is going to do better is greater.

Think about that: a promise we are going to give you care, but the result of the care is going to be less good. We are going to give you care, but it is not as good care, and it is not available care. We are going to make you wait in line, but we are going to call it care.

Care delayed is care denied. Let me say that again. Care delayed is care denied. If, in fact, you have a problem that needs attention, and you cannot get what you need, it does not matter what Medicaid does if you cannot get treatment.

If you look at the subspecialities in Medicaid, 65 percent of them do not see Medicaid patients. We have about 40 percent in primary care who will not see a Medicaid patient. We have about 65 percent of the specialities, because there is such a shortage in the specialities, that what we are saying is we are going to have 60 million people in a system that says: You get care, but guess what. It is not available; you are on Medicaid.

Senator Wyden did offer a plan, I say to Senator Corker, that would put every Medicaid patient in this country, except dual eligibles, into private insurance. So did we with the Patients' Choice Act, the first bill introduced on our side of the aisle. We take the stigma off saying you have a low-paying plan, and we give them the same kind of insurance we have right here in this body. By doing it, we save the States $1 trillion over the next 10 years. Think about that.

But that isn't nearly as important as we have a major increase in the positive outcomes for Medicaid patients. You cannot talk about Medicaid without talking about Indian health care because as you add up Medicaid to Medicare to TRICARE to VA to Indian health care, when you add all that up, the government is running 61 percent of our health care right now. No wonder we are in trouble.

I do not deny there are big problems with the insurance industry. I do not

deny we need a Patients' Bill of Rights that protects people's rights and their interests. I do not deny we need transparency in the insurance industry both on price and quality. I do not deny anything.

The question we ought to ask is, if we are going to truly reform health care, are we going to allow everybody, when they say they have health care, no matter where they get it, to have an equal shot at getting equal care?

You see, this bill does not do that. This bill puts Medicaid patients in jail and says: If you happen to be lucky enough, the lucky 60 percent to get into the line, you will be OK. And if you need a subspecialty, if you happen to be part of the lucky 35 percent, you will be OK. But everybody else is in jail. You are in monopoly jail. We are promising--the government--to do that.

A final point--and then I will yield so others can talk--is the idea that my State--Texas is a big State. It is our southern neighbor. They sometimes have a better football team than we do. They certainly did this year. We are about one-eighth the size of Texas in terms of population. We cannot afford $2.8 billion over the next 10 years, I say to Senator Cornyn. We are going to say we are going to cover 15 million people and some of those will be in Oklahoma. We cannot afford it.

What we can afford is to insure them if we make true changes in care, if we truly change and incentivize preventive care, management of chronic disease--if we truly reform health care. These bills do not reform health care. What they do is grow government.

They are not going to change outcomes, other than except they are going to limit what you can and cannot do through cost-effective comparativeness.

As we look at this bill, what we need to do is think about those we are going to promise something we are not going to deliver. We are going to call it a system, but they are not going to have it available.

I thank Senator Corker for leading this discussion, and I yield.

That is correct.

Probably not. But the Senator sparks one question. Think about this, and I have experienced this as a physician.

I care for patients and they lose their job, they have a financial catastrophe, and all of a sudden they become dependent on Medicaid. We continue to see those patients. But do you know what normally happens? You lose your insurance, you loss your job, you come on hard times and go on Medicaid. You can't go back to the doctor you had before because they are not taking new Medicaid patients. So somebody you have been with for 15 years, all of a sudden you can't get back in because they are not going to pay enough for them to care for you. It is a discriminatory system that says we will send you down the line.

That doesn't mean there are not truly caring physicians in this country, but it has to be said, outside of pediatrics, if you want to look at quality parameters, the Medicaid population ends up going to the less-qualified, the less-experienced, the less-good-outcome physicians in this country.

Mr. President, first, I would like to say thank you for presiding. You drew the unlucky number tonight and I appreciate it.

We are embarking on a process that is going to start tomorrow night and people are going to cast a vote on a bill they have not read, and saying we ought to go on with it.

For just a little history, 97.8 percent of the time in the Senate that a cloture motion passed to proceed to the bill, the bill becomes law. That is an interesting statistic, especially when we are

going to hear those who say they just want to have the debate. The fact is, that is not what is going to happen.

As one of the two practicing physicians in the Senate, I thought I would spend a little bit of time tonight talking about what I see is wrong with our health care system as well as talk about what I see as good about our health care system and then talk about the approach this bill takes. My staff has been through the vast majority of this bill. I personally have not, but I will. I will talk about how it affects us.

What is the real problem in health care today? What is it that keeps people from getting care? The No. 1 problem that keeps people from getting care is cost. It costs too much. Fully either one-fourth or one-third of every dollar we spend on health care does not help anybody get well and does not prevent anybody from getting sick.

There is an interesting study out by the Thomson Reuters report that says that $600 billion to $850 billion is wasted annually in all American health care.

When you break it down, it is broken down like this: 40 percent is health care waste, unwarranted treatment, overuse of antibiotics, use of diagnostic lab tests to protect against malpractice exposure. That accounts for $250 to $350 billion in annual health care spending. It is attributed to extra tests and procedures generated mainly from defensive medicine or Medicare's fee-for-service system.

The second biggest factor out of this $800 billion we are wasting is health care fraud. It is 19 percent of health care waste--at least $125 billion to $175 billion a year, and most of that is in government-run health care programs. Not the private--the private sector has less than 1 percent of fraud. They also have a denial rate that is one-half to a one-third of Medicare's rate in terms of denial of payment claims.

The third most important thing in terms of waste is administrative inefficiency. The large redundant volume of paperwork in the U.S. health care system accounts for $100 billion to $150 billion in spending annually.

The fourth most important area, 12 percent of health care waste is health provider errors, errors we make caused by me as the doctor, or a hospital, that causes us to spend money we should not have to spend.

Six percent of the health care waste is preventable conditions, such as somebody with diabetes getting their blood sugar out of control and ending up in the hospital; whereas if they had good care, coordinated care, it wouldn't have happened.

Of course, No. 6 is 6 percent of health care waste, and that is lack of coordinated care, where we do not coordinate the care, where doctors don't talk to one another, doctors don't talk to the hospital, doctors don't get all the information, so consequently we waste money.

So the first problem that plagues us is that cost is too high. We fully know that $1 out of every $3 we spend on health care is not helping health care. That is our pot of gold. That is where we lower the cost. Just think what health care would cost if it costs one-third less today or if it costs the same for the next 5 years. That means we could cover everybody who is not covered for free and have about $400 billion left over if we just went after where the pot of gold is.

The second problem with our health care system is we have disconnected the purchase of health care from the payment of health care, so that when I go to make a purchase I no longer use the discrimination that I use in everything else that I purchase, such as seeing if it is of value to me. I don't ask what it costs, I don't ask if it is the best way to get this, if it is the most economical way to get there. I don't question to make sure--are you sure I have to have this done? I don't necessarily get a second opinion. I don't ask, if it has to be done, where is the best place as far as efficiency and dollars to get it done.

The reason we don't ask those questions is because most of the time the money isn't coming out of our pocket because we have this perceived false belief that our insurance company or the government is paying for it. If our insurance company is paying for it, we are paying for it because for every 3.5 percent cost our company is paying for insurance, 2 percent of that would have been our wages. And for every $1 that we spend on Medicare, our grandchildren and our children are paying into that fund to pay for our Medicare. In fact, it does cost us, but we have disconnected that cost.

The third thing we have done is we have a Tax Code that says if you are fortunate enough to have your employer pay for your health care benefits, you get $2,700 more in tax benefit than everybody who doesn't have their employer paying for their insurance. You get about $100 in tax benefit if you don't get your insurance through your employer. So we have a 27-fold discrimination that advantages those whose employer pays for their health care versus those who have to buy it on their own or their employer doesn't offer it.

That is wrong. It is not fair. It is unequal treatment, and it creates this maldistribution. But, even having said that, the cost for an individual plan versus the plan bought through your employer, if you buy it in a nationwide marketplace, if you could, it would be 20 percent less than what you could buy it for through your employer. Those are the real statistics.

Then the fourth thing I see that is wrong, as both a patient--I ought to stop here in a minute and tell everybody, at 61, almost 62 years of age, I am a two-time cancer survivor. I have had malignant melanoma and metastatic colon cancer. I also have atrial fibrillation. I have been a patient. I have been on the other side of my stethoscope as a patient.

What I see is, we have limited the options for people in this country. If your employer buys your health insurance, you have very limited options. You get take it or leave it most of the time. Here is what we are providing: You get to take it. If you don't take it, then you have to go outside and you loose that $2,700 advantage, so it comes out of your pocket.

We don't have the freedom to choose within our employer. We also have the States. We heard the Senator from Maine talking about the greatly increased costs in Maine. There is a reason Maine has the massive inflation in their health care insurance. They created the State plan that caused it, that truly limited the competition. So they have seen the results of limited competition because of what they installed. But every State has an insurance commission that both decides who is eligible to sell in the State but also follows the mandates; here is what the minimum is that you have to buy in your State.

Then, of course, if you have Medicaid, you have limited options because 40 percent of the physicians in this country will not see you. If you have Medicare, you have limited options because now about 15 percent of physicians, fast rising to 30 or 40 percent of the physicians in this country, aren't going to see you.

Then if you have VA, you get VA and that is it. You don't get to choose your doctor or you don't even get to choose your location. Here is where you will be, no matter how many miles it is, and here is the doctor you will see. The same thing with TRICARE essentially because TRICARE has limited coverage in terms of availability of all the physicians.

The fifth thing I see that is wrong is there is an absolute lack of transparency as to what something costs and what you can expect as far as quality outcome. That makes it hard to know how to buy, where to buy, or who to buy from. Who do you trust? So if there is no transparency in either quality or price, you are going to have a tough time making a decision. All of the things I am describing describe a lack of liberty, a lack of freedom.

We have government mandates. Have you ever gone to a hospital--this is a great question. One of my constituents wrote in and told me this, and I never had thought about it. Go to a hospital in the middle of the day and try to get a parking spot. Then go to a hospital at 10 o'clock at night, and the parking lot is almost empty. What you are seeing in the difference in the parking lot is the administrative bureaucratic overhead that is required in a hospital to manage the mandates that the government has put or the insurance company has put on the hospital.

If you look at it, fully one-third of the people in every hospital in this country don't do anything to help anybody get well. They are filling out forms, they are pushing the paper,

much like this study I mentioned from Thomson Reuters.

Then we have the insurance mandate. What is wrong? If, in fact, you have a preexisting illness, you don't get insured. That is wrong. We need to fix that. Or if you get sick, insurance companies have figured out a way to drop you. That can't be right. That is why you bought insurance in the first place, and that is not just in the health insurance industry. Try filing a claim for a new roof on your house and see what your insurance costs do next year or if they will insure you. We get hail all the time in Oklahoma and we get roof damage and a lot of times if you have that 2 out of 10 years, they will not even reinsure you. So you have to go find somebody else.

It is a practice of risk management that they are using that doesn't think about the potential market of who their customer is. So I agree we ought to fix those things.

Then we have the costs. Already the Senator from North Dakota tonight talked about drug prices. The one thing he didn't tell everybody is that the reason drugs are cheaper in Canada is because they threaten not to honor intellectual property of this country.

There is a real good way to make sure drug prices go down. Both the Bush administration failed on this and the Clinton administration failed on this--and this administration. If Canada wants to tell our drug companies what price they will pay, then we will tell them what we will pay for their lumber, and we will tell them what we will pay for anything else they want to import to our country. But we put all the focus on the drug companies instead.

So I am going to get to my point. The other thing that is wrong is, on average it costs $1 billion per new drug just to go through the FDA process in this country because we have such a litigious society, that it costs two to three times more to approve a drug in this country than it does anywhere else in the world.

We have drugs that are fantastic drugs that are made by companies in this country that are not allowed to be sold in this country that have passed all the safety and efficacy standards of the European common market, but they can't get them through our Food and Drug Administration because the Food and Drug Administration is worried about somebody criticizing them if they ever make a mistake. They met the standards, did it right, recalled it, now they are afraid to approve anything because they are afraid somebody will be critical of them.

Another thing that is wrong is we have the lack of any real market forces. Insurance companies really don't have to compete.

They really don't have to compete. The government sets the price for everything, essentially, because Medicare says what they will pay and everything else is priced off that.

Here is another thing that is wrong with our health care system. We are starting to experience it. There is a maldistribution of physicians both in terms of geographic location and physician specialty. One in 50 graduates of med schools last year went into primary care. Everybody else went into specialty and subspecialty residencies. Why did that happen? The reason it happened is because the earning power of somebody who has 7 years of medical training is one-third of somebody who has 8 or 8\1/2\ or 9. How did that happen? Because Medicare set the payment rates. Medicare set the payment rates, so they created a maldistribution in terms of the payment for physicians.

Another thing I noticed as a practicing physician and as a patient is that our whole system right now has its emphasis on sick care, not on preventing disease, not on prevention, not on the maintenance of chronic disease. We wait until people get sick and treat them. That is expensive. The reason it is that way is because Medicare won't pay for prevention. They refuse to pay for prevention. If you sit down with a patient in your office, a Medicare patient, and spend the time to go through the risk factors and the lifestyle changes and their medicines, the things they need to do, you will not be compensated enough to pay the electricity bill for that office visit. So what has happened is we have incentivized people not to spend time with the patient. We have incentivized them to see more patients for shorter periods of time and not listen to the patient and not spend the time on prevention because our dollars have been incentivized against it.

Then, finally, government systems are designed to be defrauded. If you think about it, it is easy to make $500,000 a month off Medicare; it is hard to get caught. All you have to do is know a whole lot about medicine, have a little bit of guts, and set up a vacant office somewhere and put one computer in it and run everything over the line, and you can rip off Medicare like crazy. We know the drug dealers in Florida are starting to shift away from drugs and into Medicare fraud because it is easier to do. They can make more money. It is harder to get caught, and when you do, the penalties are much less. It is designed to be defrauded, but we haven't changed that.

I have talked about the problems. Let me talk about what is great about American health care.

I want to make the point in a minute that the worst thing we can do in trying to fix what is wrong is destroy what is right. We have the greatest acute care anyplace in the world. If you get sick, there is no better place in the world to get sick than in the United States. I don't care where you are. The statistics bear that out. There is no question. If you get cancer in this country, you have a 50-percent greater likelihood of being alive 5 years from now than anywhere else in the world. It really doesn't matter what type cancer. There are some differences on some, but overall you are 50 percent more likely to be alive.

The third thing that is great about our country is, innovation in health care is two-thirds of the world. Actually, last year it was 74 percent of all innovation in health care came out of this economy. We have invested in the research. We have the scientists. We have the researchers who have pulled together technology, thought, experience, and research, and come up with great innovations that make big differences in life expectancy and quality.

The other thing is we have a very skilled workforce. We have some shortages. Our nursing shortage has been created by the government because we created a health care system that has both hospice care and home health care, but we made the only way that can effectively work is through registered nurses. So we sucked all the registered nurses out of the hospitals because of time constraints and lack of holiday work and lack of shift work. The best nurses want to go where they don't have any of those things. We created a shortage when we could have created a different class of somebody doing home health care rather than an RN. But that is what we have done. We have created this sucking sound, as Ross Perot used to say, and sucked the nurses out of the hospitals. Now we have this critical shortage of nurses in our country because of what the government did.

The other thing besides the skilled workforce, the nurse practitioners, the PAs, nurses, physical therapists, pharmacists, radiologists, doctors, surgical nurses--they are great in this country.

Then we have great medicines. If you think about it, the combination of medicines that saved my life with metastatic colon cancer were all developed here. Six months of chemotherapy, of being sick every day, has been worth every morning I see the Sun. It is this research, the investment in NIH, the quality of research, the committed doctors who will do the research, committed doctors who will take care of you when you are sick and you don't feel like communicating with anybody, but yet they are patient with you--they love you, they nurture you. We have a great system here.

If you have a cardiovascular event, this is the best place in the world to have one. If you have a heart attack, a stroke, if you get cancer, if you have an acute fracture of a limb or joint degeneration, this is the best place in the world to have it.

So I have outlined the problems, which are big, and the things that are good. What do we do with that? Our goal ought to be to not destroy all these good things while we fix the things that are not good.

How did we get in trouble? How did we get to where we have the highest percentage of our GDP, this thing that really limits people in care, cost--how

did we get where we are? Why is it? Part of it has been innovation. About 30 percent of the cost increase we see in our country is because of innovation. It takes money to get innovation. When innovation comes out, we have to pay for the research that was not paid for upfront. About 30 percent of the health care inflation we see is from new products, new innovation, new ideas, new treatments, new strategies or procedures. But the rest of it goes back to this Thomson Reuters, where we have this inefficient delivery system of health care.

A question I asked my staff--and we did the research--what was health care inflation before 1970? Do you realize that most of the time it was less than the regular increase in inflation? What was the difference? What happened? What happened is the government got involved in health care. We created demand that was price-controlled demand, and all of a sudden the bubble started squeezing up.

The other point I wish to make is that most people don't realize that 61 percent of the health care in this country today is run through the government. If we have a problem with health care, we have to look at not where the 39 percent of it is but where the 61 percent is. Let me explain what that is. That is Medicare, TRICARE, VA, Medicaid, Indian Health Service, SCHIP, DOD, and FEHPB. That accounts for 61 percent of the people in this country who have health care. They are getting it through the government now. Our answer is more government? Our answer to the solution is more government?

What should our goals be? Our goals should include access for everybody; affordable prices; liberty to choose what is best for you and yours, not limited by your State, not limited by the Federal Government, it should be your choice; freedom to choose your caregiver. You don't get that in Medicaid. You don't get that at the VA. You don't get that at Indian Health Service. You limitedly get it through Medicaid. Another goal is security in your health care, knowing that no matter what happens, you will have health care. Those are things I think the Presiding Officer would agree with.

I am joined on the floor by the other physician in the Senate, Senator Barrasso from Wyoming. I welcome him.

I wanted to spend 1 additional second outlining a few things.

Here is the bill we have on the floor, the Reid substitute. I will not talk about the parliamentary shenanigans that have gone along with what we are doing. The fact is, we are going to have a debate on health care. It couldn't have been said any better than by Senator Snowe. Every major piece of legislation that has affected most people in this country has occurred on a bipartisan basis. If this gets passed, you will see a revolt in this country because it is not what the vast majority across party lines want to see. We need to meet in the middle.

Just so I can tell you what is in here or what is not in here, there is no provision in here guaranteeing that taxpayers will not finance abortion. There is no provision prohibiting the rationing of health care. You will see rationing of health care with this bill. We are seeing it now in Medicare more every day. CMS is not supposed to be doing it, but they have a reason not to do it. There is a law that says they are not supposed to do it, but it doesn't prohibit them. Now they are rationing about 17 things. They have made a decision on practicing medicine. You will see that.

There is zero number of Senators who are going to be required to enroll in the health care bill we will put everybody else on. There are nine new taxes created in this bill, nine new separate taxes. There are 13 pages in the bill's table of contents, single-spaced. This bill weighs 20.8 pounds. There are 36 pages in the CBO explanation of what they think it might or might not do. It has 70 new government programs. Think about what that means in terms of bureaucracy and then think about your choices, about who you want taking care of you and whether you and that caretaker, that physician are going to get to decide what is best for you or some of these 70 new government agencies. And 1,697 times in this legislation we allow the Secretary of Health and Human Services to create, determine, and define critical things in this bill and write the regulations--1,697 times. There are going to be 1,697 new sets of regulations in health care in this bill alone. There are 2,074 pages. There are 2.5 million people who will lose their health insurance with this bill who have it today. They are going to get moved into some government program. There are still going to be 24 million people left without health insurance, if this is fully implemented, according to CBO. This bill costs $6.8 million a word. It is $1.2 billion per page. Ten billion will be needed every year for the IRS just to follow the regulations for the tax collection in this bill. That isn't even considered in the CBO score. There is going to be $8 billion in taxes levied on uninsured individuals. There is going to be at a minimum $25 billion a year in increased mandates on States for Medicaid; there is $28 billion in new taxes on employers not providing government-approved plans; there is $100 billion of fraud annually in Medicare; there is $118 billion in cuts to Medicare Advantage; there is $465 billion in total cuts to Medicare; there is $494 billion in revenue from new taxes and fees levied on individuals, on American families, and businesses. Mr. President, $2.5 trillion is the non-Enron accounting cost for this bill.

Finally, there is $12 trillion worth of national debt today, and this bill by itself will take it to $15 trillion in 10 years. It will increase the national debt in less than 10 years by $3 trillion.

So with 61 percent of the health care in this country already supplied by the government--and either bankrupt or going bankrupt or not giving the care that is promised; look at Native American care--we are going to do more government health care.

Senator McCain had a great analogy the other day on this bill. This bill starts collecting taxes right away. The American people need to know the reason there is the delay in the onset of the benefits in this bill. It is because that is the only way they can make it score and look like it is not spending the amount of money it is spending.

But he used this analogy and I thought it was really great: This bill is like you buying a new home; you go get your mortgage, and you start paying on your mortgage, and you get ready to move in the house, and they say: Uh-oh, the deal was you can move in in 5 years, because that is when the benefits start, 5 years from now. But we want you to pay on it for 5 years before you get to move into it.

None of us would do that. Yet that is exactly what this bill does. It is not a bait and switch. It is just deceptive, and it is dishonest in its accounting. And, of course, Washington has been dishonest. We use Enron accounting. Anything that makes it look less expensive or us look better, that is how we account for it.

Finally, I would say this, and then I will yield to my colleague and fellow physician, Senator Barrasso.

Of the things that are wrong with health care in America and the things that are right--the things that are right are because we have a patient-centered system; the things that are wrong are associated with a government-centered system.

This is a government-centered health care fix, and it is not even a fix. It does not address malpractice costs. It is somewhere between $100 billion and $175 billion a year in tests we are ordering that people do not need because we refuse to address the tort system in this bill.

What we need is a patient-centered result. What we need is meeting in the middle to solve this problem for the American people.

Abraham Lincoln said: America will never be lost by being destroyed from the outside. If we falter and lose our freedoms, it will be because we have destroyed ourselves.

This bill is the path to destruction for health care in America. Eighty percent of the people in this country will get along just fine with this bill. Twenty percent are going to suffer drastically under this bill because it totally ignores the clinical practice of the art of medicine. Everything is based on a government-run, government- mandated, government-controlled fiat that takes away your liberty, takes away your choice, takes away your freedom; and now we will move physicians from having to be 100-percent advocates for the patient to an

advocate for the government first and the patient second. That is the first health care outcome we could have.

Senator Barrasso.

Mr. President, in answer to my colleague's question, there is not an incentive. This bill is full of mandates. And what it does not mandate it sets up panels to mandate. It sets up panels of bureaucrats to mandate. The real difference on this bill--and I believe we have big problems with the insurance industry, but I do not think you eliminate it. I think what you do is you clean it up and make it have to be competitive and fair and open and honest. What the bill does is it mandates.

Just this week, the Preventative Services Task Force came out with new recommendations for mammograms. If you are only thinking about cost, they are great recommendations. If you are looking at it only from cost--how do we most effectively spend the dollars--their recommendations are absolutely right. But if you are thinking about health, their recommendations are absolutely wrong.

You ask the thousands upon thousands of women last year under age 50 who had their breast cancer diagnosed early with a mammogram what they think about the Preventative Services Task Force's recommendation and listen to what they have to say. What they are going to say and what they are going to tell us is that would have made me odd woman out because I would not have had a mammogram. I am talking not high-risk patients. What they are talking about not screening--and that is what the majority of these mammograms find, with no symptoms, no increased risk--you are going to see that multiplied one-hundredfold in this system.

I know the Senator is old enough to have been trained in medicine the same way I was. There are three real tenets in medicine. The three tenets they drill into you are--the first thing is do not hurt anybody. Whatever you do, try not to hurt anybody. And in the practice of medicine and the art of medicine sometimes that happens, we do hurt people. Sometimes we hurt them on purpose to try to get them better. But the first is to do no harm.

The second is to listen to the patient. Well, the patient at this time in America is the American citizenry, where 85 percent of the people pretty well like what they have, and they want the good kept as we fix what is wrong.

Finally, the third tenet of medicine that almost every doctor is taught is,

if it has already been done and it is not working, do not do it again, and do not keep doing it.

Well, let me tell you something. Medicaid is not working. Indian health care is not working. Medicare is broke. The States are broke under the weight of Medicaid. We should give great pause as we break the three tenets of medicine in hopes of saying we reformed health care.

When President Obama spoke to us under a joint session of Congress, this is what I believe he should have said. This is an important matter for America. It is important to us economically. It affects every individual in this country. And what he should have said is: I have not been leading very well on this because we are way over here on one side on this issue, and I am going to admit I have not been leading very well. But here is what I am going to do. I am going to bring us together in the middle where we can all agree on--it is kind of like Senator Enzi's 80-percent rule. It is a great rule. Senator Enzi has joined us. He is the ranking member of the Health, Education, Labor, and Pensions Committee. I want to bring us together and find something on which 80 percent of us can agree.

Had he done that, he would have been a hero in solving the problems in which we find ourselves. Instead, we are going to try to pass something that, before we are through with it, the vast majority of Americans are not going to want. And if you do pass it, and he does sign it, they are going to revolt.

So as our friend Lamar Alexander said: What we ought to do is start over. We ought to fix one step at a time the things we know are most important, as the author and promoter of association health plans suggests, where we increase the buying power; transparency in the insurance market; risk reevaluation so people can't cherry-pick; eliminate preexisting illnesses so they can't cancel insurance. All of those things we can do without creating all of these new programs, all these 1,697 times that the Secretary of HHS is going to write the rules and regulations.

I thank Senator Barrasso, No. 1, for his insight and experience. I would leave our colleague, the senior Senator from Wyoming, with this thought: You have two doctors down here who happen to be Senators, who have well over 50 years of practice experience. I had a business career in the health industry prior to going into medicine. We diagnosis this bill as sick. We diagnosis it as something that should be pulled from the market, just as the FDA pulled Vioxx. It will not solve the problem; it will make the patient sicker.

With that, I yield the floor.

Mr. President, I call up amendment No. 2785.

Mr. President, I ask unanimous consent that the reading of the amendment be dispensed with.

Inquiry, Mr. President. It is my understanding I am going to have 2 hours during this period of time under unanimous consent.

I reserve the remainder of my time and yield to the chairman and ranking member.

Mr. President, the reason we are having the debate now is because nobody would have the debate earlier. It is important for the American people. I don't have any opposition to veterans care. As a matter of fact, I support keeping our commitments. But as this thing wound out, on October 28 it came to the floor. Part of my amendment, when it actually came out of committee, was in the bill. It was taken out before it came to the floor, not by the members of the committee. It was taken out. But the very fact that we make an issue, because somebody wants to debate a bill and offer amendments on a bill, and then we are supposedly antiveteran because we think maybe we ought to pay for some things we do around here, so because we want to pay for it, we are cast aspersions that we don't want it to be debated. The worst thing that happens in this body is we pass bills that the American people have no idea about because we refuse to debate them.

I apologize to no one for having put a hold on this bill for a very good reason. The very good reason is this: Our veterans demonstrate courage greater than we ever demonstrate in this body. We ought to model that same courage. What is the courage I am talking about? The courage to make priorities, to make sure we keep those commitments. This bill, as it is written now, will cost $3.7 billion over the next 5 years. I think we ought to do that for these veterans. But I also think their sacrifice should not be in vain and stolen and paid for by their grandchildren. I believe we ought to pay for what we are going to do.

It is interesting that the Senator from Hawaii mentioned speaking at the World War II memorial. This bill, as written, excludes World War II veterans from the benefit. It excludes gulf war veterans from the benefit. What about them? Is the reason the other veterans, the Vietnam war veterans, the Korean war veterans were not included is because we thought we couldn't afford it? I think that is probably the reason. Which begs the question, if in fact we want to honor veterans, we ought to treat them the same, one, and we ought to have the courage to make hard choices about how we pay for it.

It is easy to charge this money to our grandkids. I have no doubt that is what we will end up doing. But the biggest threat facing our country today is not Islamic fascism and Islamic terrorism. The biggest threat facing the country today is the fact that every young child born today will encounter $400,000 worth of debt for benefits they will get nothing from. When we calculate the interest cost on that, by the time they are 25, they will have been carrying a debt load of $1,119,000.

As I look at my colleagues who want to do this but don't want to pay for it, I am bewildered to think that we can call and honor the courage and service of our veterans without taking some of the same courage to make some hard choices about funding of other things that are not nearly as important as our veterans. We can't do both. We can't continue down the road we are on. We can't continue to spend the money we are spending and borrowing, 43 cents of every dollar we spent this last year, borrowing it from our grandkids. It won't work. We will fail as a nation.

Look at President Obama's recent trip to China. What was the message that emerged? They are worried about us financially. They are worried about our deficit spending. Why are they worried? Because they own close to $1 trillion worth of our debt. They now impact our foreign policy decisions only by the fact that they own so much of our debt.

Can we continue to do this and have a free America? Can we continue to do this and our children have opportunity, at least to the level we have experienced? What are our veterans fighting for? Why did they put their bodies at risk, if it is not for a greater future for the country?

When we think about this past year--and it will be worse next year, it will be 44, 45 cents borrowed of every dollar we spend--do we not have an obligation to our grandchildren as well as our veterans? This isn't even a hard vote. Our entire contribution to the United Nations is wasted in the fraud of the peacekeeping we contribute to. We contribute 25 percent of the United Nations money, and we have reports and studies and leaked documents that show the vast majority of the money we put in the United Nations gets defrauded from the United Nations.

We are going to get to make a choice with this amendment. We will say we will treat all veterans the same, No. 1, and we are actually going to pay for it by saying it is a greater priority to take care of our veterans than to fund a corrupt, fraudulent peacekeeping force as run through the United Nations. That is what we are going to say.

If this amendment passes, it will send a wonderful signal to the United Nations to clean up their act. It will send a wonderful message to our children and grandchildren that we will finally start acting responsibly, and it will send a great message to veterans that we do care and we care enough to make sure the sacrifice they made will not be squandered by us not making hard choices.

We owe a lot to our veterans. The No. 1 thing we owe them is to make sure what they fought for and the future we have is secure in our children and grandchildren's generation. It is not secure today, based on the fiscal situation we find ourselves in.

I reserve the remainder of my time.

Madam President, may I inquire how much time I have remaining?

Thank you, Madam President.

I want to go back to the start of this again. The American people need to know what a hold is. What is a hold? A hold says that a bill is trying to go through the Senate without debate, without discussion, that by unanimous consent everybody agrees we ought to pass a bill the way it is. Unfortunately, 70 percent of the bills that go through the Senate pass that way. The American people get to hear no debate, get to have no knowledge about what is in the bill, whether there is controversy about what is in it. As a matter of fact, they do not know that the bill on the floor is actually different from the bill that passed out of committee. It has been modified, not with the vote of the committee but with the direction of the chairman only.

So the purpose of our holds is either you are against the bill--and I have no secret holds. Everybody here knows that. When I hold a bill, everybody knows the bills I hold, and I give a reason for why I hold them. I do not hold them sheepishly. The purpose for a hold is to develop debate, to have the very discussion we are having on the floor.

This bill was filed October 28. It was brought to the floor the week before

last without the ability to amend it, debate it, or discuss it. So the reason we are here today is so we can do just that.

I have stated numerous times--I have stated it to the chairman of the committee and the ranking member of the committee and others--I do not oppose--as a matter of fact, I am for providing for our veterans. What I am opposed to is us sinking our grandchildren in debt.

The Senator from Alaska makes the claim or insinuates that I was here when the tax cuts came through. I was not. I believe when you do tax cuts you match them with spending cuts.

There is $350 billion a year in waste, fraud, and abuse that goes through this government every year. Not one amendment out of over 600 that have been offered has been agreed to by this body to eliminate some of that waste--not one.

Everybody who has spoken against this amendment or for this bill, with the exception of Senator Burr, has a 100-percent voting record for spending money. Not once do they vote against any spending bills, not once since I have been in the Senate--5 years. Not one of those who are opposed to paying for this has said: I see something wrong with this spending bill. It is not a priority. We ought to cut it. Therefore, I am not going to vote for it.

I have had criticism because the first year I was here I actually voted for a war supplemental. But at that time, we had a deficit of $110 billion, not $1.4 trillion. At that time, we had an economy that was growing, not an economy on its back. At that time, we had not totally mortgaged our children's future.

It is time for all of us to change. It is time for all of us to make the same decisions everybody outside of Washington has to make every day, which means you have to make a choice. You get to make a choice on what is a priority and what is not. For, you see, our body, the supposed most deliberative body in the world, has a bias. The bias is this: Offend no one. Offend no one. How do you do that? How do you offend no one? You offend no one by taking the government credit card out of your pocket and putting it into the machine and saying: We do not have to make those hard choices. We are not going to offend anybody by cutting programs. We are not going to offend anybody with the $50 billion a year of waste at the Pentagon. The fact is, 2 years ago the Pentagon paid out performance bonuses of over $6 billion to companies that did not meet the performance requirements.

Sadly, not one American, not the Federal Government, got any of that money back. None of it came back because the other side of the story is, we fail to do oversight. We fail to do the hard work that does not give you a headline. That is very hard work to hold the executive branch and agencies accountable. So our veterans do sacrifice.

I am for the Caregivers Act. I am for us doing all these things. But I am only for them if, in fact, we will start making the same hard choices our veterans make, the same hard choices everybody else in this country makes when it comes to making a decision about the future.

You see, a lot of people in our country today are underwater on their mortgages. They are underwater on their mortgages. Guess who else is. We are as a nation. We are underwater. Let me show with this chart, for example, what the financial situation is with our country.

Medicare is broke. Part A will run out of money in 2017. We have 50 million baby boomers--I am one of them--who are going into Medicare in the next 8 to 10 years. So not only is the cost per Medicare patient going to go up, but we are going to add 50 million to it. It is broke.

Medicaid. It is broke. It comes out of your general tax revenue. But the States are broke over their share of Medicaid.

The census. It is broke. It is going to cost 2\1/2\ times what the last one did. It is total mismanagement by the Federal Government.

Fanny Mae and Freddie Mac--broke to the tune of $200 billion of your money, each one of them; $400 billion that your kids get to pay back, your grandkids. They do not get the opportunities because they are both broke. We have done such a wonderful job.

Social Security. It is the easiest to fix, but it is essentially broke because we have stolen $2.6 trillion from it. And then we are not being honest with the American public about what our true deficit is because when I said a minute ago that our deficit was $1.43 trillion, that is not true. That is Enron accounting. That is Washington accounting. The real deficit is well over $1.5 trillion because we stole more money from Social Security. Guess what. Next year, for the first time in the history of Social Security, more money will be paid out than will be paid in. For the first time, it runs in the red next year. We owe money, so technically it is not broke yet--until some of that $2-plus trillion goes back into it--but it is essentially broke.

How about the post office? They just announced their loss for this year. They are going to have a bigger loss next year. It is broke.

Cash for clunkers. That was broke when it started.

The highway trust fund. It is broke. We do not have enough money for what we are obligated to pay out. It is broke.

Now we are talking about government-run health care? A $2.5 trillion program? That is what the real number is on it when you get the Enron accounting out of the bill that Senator Reid introduced last night-- $2.5 trillion.

And now we are saying we do not have the courage to pay to take care of our veterans. I do not think the American people are going to tolerate this much longer, nor do I think they should tolerate it--that we will continue to steal the opportunity and future of our children.

I think the Senator from Alaska can be forgiven for not knowing all the abuse, fraud, and waste in the U.N. because in every country he mentioned, U.N. peacekeepers have been accused of rape and pillaging the very people they were supposed to have been protecting. In every country he mentioned, U.N. peacekeepers we paid for are raping the very citizens they are supposed to be protecting. Yet we do not have the courage to say: Time out. We are not sending you any more money until you clean up the mess. No, we are not going to do that. We are not about to do that. What we are going to do is we are going to say we will take the money for the veterans from our grandchildren and we will not make the hard choice. I think it would be a wonderful message to send to the United Nations that maybe they ought to start being transparent about where the money goes. Do you realize nobody can know where the money goes? You don't get to know. I, as a Senator, don't get to know. The President pro tempore doesn't get to know where the money goes. Yet your country puts $5 billion a year into that and you have no idea. The only way we find out is occasional leaks.

By the way, of all those U.N. peacekeepers who have raped and pillaged, not one of them has been convicted. Not one of the agencies, in terms of their eight programs that have been incompetent and wasted money, have been convicted. They are immune to conviction. The waste, fraud, and abuse of this country is only exceeded by one organization, and that is the United Nations. Yet we don't have the courage because the State Department is against this amendment, and they sent a letter outlining why they are against it. I am going to put into the Record why they are wrong. I ask unanimous consent that at the end of these remarks, my rebuttal statement in response be printed in the Record.

The State Department Bureau of Legislative Affairs opposes this amendment. It lists a number of programs as reasons to support the U.N. and oppose the Coburn amendment. Many of the programs and activities the State Department listed have experienced severe problems in execution or are taking credit for activities by national governments or private entities.

Let's take the recent elections in Afghanistan. The United Nations cannot account for tens of millions of dollars provided to the Afghan election commission, according to two U.N. audits--these are confidential; they weren't released; we just happened to be fortunate enough to have people who would give them to us--and interviews with

current and former senior diplomats. The Afghan election commission, with over $20 million in U.N. funding and hundreds of millions of dollars in U.S. funding, facilitated and helped mass election fraud and operated ghost polling places.

Should we keep sending them money for incompetence, waste, and fraud?

``Everybody kept sending money'' to the elections commission, said Peter Galbraith, the former deputy chief of the U.N. mission in Afghanistan.

Nobody put the brakes on. U.S. taxpayers spent hundreds of

millions of dollars on a fraudulent election.

This is a deputy to the senior U.N. official in Afghanistan. He was fired last month. He protested the fraud and he got fired by the U.N., that wonderfully competent organization.

As of April 2009, the U.N. had spent $72.4 million supporting the electoral commission, with $56.7 million of that money coming from the U.S. Agency for International Development. The Special Inspector General for Afghanistan Reconstruction states that the United States provided at least $263 million in funding for that election.

In one instance, the United Nations Development Programme paid $6.8 million for transportation costs in areas where no U.N. officials were present. We paid transportation costs, but no U.N. officials were present. Why did we pay it? Where did that money go? Where is the money?

Overall, the audits found that U.N. monitoring of U.S. taxpayer funds was ``seriously inadequate.''

In other words, it is there, they send it out, they don't have any idea, but you can bet well-connected people at the U.N. are making millions off U.S. dollars.

How about the monitoring of nuclear programs in North Korea and Iran? In 2002, the North Korean Government used United Nations Development Programme money--UNDP money or aid--to purchase--this is aid for them for development from the U.N.--they purchased conventional arms and ballistic missiles. With money we gave the U.N., the U.N. turns around, gives it to North Korea, and they buy missiles and arms. There is a real problem at the U.N. We will not face up to it.

It also transferred millions of dollars in cash to the Government of North Korea, with no oversight on how the money was spent--no oversight, just handed them millions of dollars in cash.

In September 2009, North Korea announced to the United Nations Security Council that it was almost complete in weaponizing nuclear materials from its nuclear reactor. Last week, North Korea announced the processing was complete.

We helped finance it through the United Nations. We helped finance it through the United Nations.

As of this morning, Iran had rejected the U.N. offer to send enriched uranium out of the country to prevent it from developing nuclear weapons.

We don't know how much U.N. money has gone in there yet, but I promise I will try to find out. But I can guarantee that millions of our dollars have been wasted that could pay for our veterans or we can borrow it from our children.

U.N. contribution: Funding 17 U.N. peacekeeping operations, including those in Haiti, Liberia, Lebanon, Darfur, and the Democratic Republic of Congo.

U.N. peacekeeping operations are plagued by rape and sexual exploitation of refugees. From 1994 forward, 68 separate instances of rape, prostitution, and pedophilia--68 separate times--and we pay half the U.N. peacekeeping costs. We don't manage the money; the U.N. manages the money.

What would happen if U.S. troops were doing that? Yet we have no control.

In 2006, reported BBC News: Peacekeepers in Haiti and Liberia were involved in exploitation of refugees. You can read that in the BBC News of November 30, 2006, if you want to look it up.

In 2007, leaked reports indicate the U.N. has caught 200 peacekeepers for sex offenses in the past 3 years, ranging from rape to assault on minors. Not one of them has been prosecuted, not one.

Just this month, Human Rights Watch reported that Congolese Armed Forces, supported by U.N. peacekeepers in the eastern Democratic Republic of Congo, have brutally killed hundreds of civilians and committed widespread rape in the past 3 months in a military operation backed by the United Nations. That is this month. Yet we continue to send billions of dollars every year to the United Nations.

I will be happy to yield for a procedural question.

I do not plan on consuming all of it at this time. I have about 10 or 15 minutes more to go, and I will be happy--is the Senator wanting time?

I have no objection to that.

Going back to the Congolese, most of the victims were women, children, and the elderly. Some were decapitated. Remember, these are U.N. peacekeeping forces--peacekeeping. Others were chopped to death by machete, beaten to death with clubs as they tried to flee.

They may not have been actual U.N. officers, but the U.N. was supplying all the logistics, all the transportation for this group of people. Where is the oversight?

U.N. contribution: Compiling forecasts of global agriculture production and identifying areas of likely famine and the risk of severe hunger, to facilitate food assistance. We make a contribution to the U.N. The Food and Agriculture Organization is currently hosting a U.N. conference, a food summit in Rome, where the opening speaker is Zimbabwe President Robert Mugabe who has literally destroyed his Nation, which used to be the bread basket of Africa and which is now dependent on food imports. We are helping to pay for President Mugabe-- who can't travel hardly anywhere else in the world because he is such a rogue dictator--we are sponsoring, through our dollars, meetings where he is the headline speaker.

The meeting was branded a failure within a couple of hours

of its start after the 192 participating countries

unanimously rebuffed the United Nations' appeal for

commitments of billions of dollars in yearly aid to develop

agriculture in poor nations.

It is not because they don't care about people having problems with food; it is they recognize the U.N. is ineffective at doing that and they are not going to commit more money, but we continue to commit more money.

The U.N. Environment Programme spends $1 billion a year--20 percent of it our money--on global warming and its effect on agriculture.

The U.N. has coordinated efforts by the global shipping industry and governments to prevent and respond to acts of piracy on the high seas.

It was totally ineffective. Do you know why we decreased the amount of piracy on the high seas? It is because of Task Force 51, which was formed by the U.S. Navy because the United Nations was totally ineffective in accomplishing that purpose.

I could go on and on. But the fact is, the United Nations is not only morally bankrupt in its leadership and efficiency, it is filled with fraud, waste, and, as noted, tremendous acts of violence through the peacekeeping armies it sends throughout the world. Yet we are going to have people say we shouldn't take some of that money away. We are not taking all the money away with this amendment anyway; we are just taking a small portion to pay for our bill.

We are going to have people actually vote to continue to do these things, instead of taking care of our veterans and not steal it from our children.

I heard Senator Tester speak about the wonderful things in this bill to help people who drive to VA clinics and VA hospitals. There is a better idea. If a veteran is deserving of care, give him a card. Let them go wherever they want.

Why should they have to drive 160 miles, when they can get the care right down the street from somebody they trust and they know. But instead we say: We are going to promise you health care, but you can only get it here. Real freedom for our veterans--real health care for our veterans is to honor their commitment by saying: Here is your card, you served our Nation, go get your health care wherever you want. If you want to get it next door or if you want to go to the M.D. Anderson or Mayo Clinic, you can. You can go wherever you want because we are going to honor your commitment.

I recognize our VA hospitals have done a magnificent job in improving their care, but I will tell you the test for the VA hospital system is this: Go ask any doctor coming out of training who experienced part of their time in a VA hospital and ask them to choose for their family: Do you want your family treated at a VA hospital or somewhere else where you trained? Nary a one will pick a VA hospital because the care isn't as good. It is better, and it is getting better all the time, but it is not as good. So we are saying to veterans: Here is where you have to go, when what we should say is: Thank you for your service. Here is what we owe you. Go get care wherever you want to get it or wherever you think you can get the best treatment.

On prosthetics, the VA is the best in the world. Nobody compares. On post-traumatic stress disorder, they are the best in the world. Nobody can compare. They are underfunded in those areas. This bill is right on that. But the real commitment is to give the choice. The veteran fought for freedom. Give them the choice, the freedom to choose what they want for them.

Why is it important we change how the Senate operates in terms of making hard decisions? The reason it is important is there are millions of these little girls out there. I have five of them, five grandkids just like her. She has a little sign around her neck. She says: ``I am already $38,375 in debt and I only own a dollhouse.'' Of course, when you divide up the $12 trillion which we passed this week in directly owned debt; it doesn't count the billions--I mean the trillions--we have borrowed from Social Security and the other trust funds, such as the waterway trust fund and all these other organizations we have stolen from, it doesn't include that. But that is for every man, woman, and child in this country. It is over $30,000 now, this year. I think when you look at her, you have to say, certainly, we ought to be making some changes. By the way, between now and 2019, that number goes to over $96,000 per man, woman, and child. But she is a child. This doesn't apply to veterans, but it applies to almost everything else we are doing.

This is what Thomas Jefferson said:

The democracy will cease to exist when you take away from

those who are willing to work to give to those who would not.

If you think about what is happening in our country right now and how things are being shifted, what we are doing is, we are on the cusp of a dramatic change in our country in terms of balance. This huge bill, which I will talk about later, is a major move in that direction. Senator Byrd and I were talking this morning about this. In this bill is a 5-percent tax on cosmetic surgery. Just the day before yesterday, the U.S. Preventive Task Force Services recommended--because it is not cost effective--that women under 50 not get mammograms unless they have risk factors. You tell that to the thousands of women under 50 who were diagnosed with breast cancer last year with a mammogram. Tell them it is not cost effective. But also in this bill is a 5-percent tax on breast reconstruction surgery after they have had a mastectomy. They are going to tax having their breasts rebuilt after their breasts have been taken off because it is an ``elective'' plastic surgery. It is an elective cosmetic surgery. We are going to have a tax on it because we have taxed elective cosmetic surgery.

We are in trouble as a nation because we have taken our eye off the ball. I see the majority whip is back. I told him I would be happy to yield. At this time, I will reserve the remainder of my time and yield the floor to the majority whip.

Exhibit 1

Rebuttal of State Department Talking Points on Coburn Amendment 2785

The State Department Bureau of Legislative Affairs opposes

the Coburn amendment to S. 1963, the Caregivers and Veterans

Omnibus Health Services Act of 2009 (S. 1963). In its formal

opposition, it lists a number of programs as reasons to

support the U.N. and oppose the Coburn amendment.

Many of the programs and activities that the State

Department listed have experienced severe problems in

execution or are taking credit for activities by national

governments or private entities. (Their document is after the

rebuttal).

Below is a list of those ``accomplishments'' and facts that

should be considered.

U.N. Contribution: Facilitating and holding elections in

Afghanistan and Iraq (U.N. Secretariat).

Response: The United Nations cannot account for tens of

millions of dollars provided to the troubled Afghan election

commission, according to two confidential U.N. audits and

interviews with current and former senior diplomats.

The Afghan election commission, with tens of millions in

U.N. funding and hundreds of millions in U.S. funding,

facilitated mass election fraud and operated ghost polling

places.

``Everybody kept sending money'' to the elections

commission, said Peter Galbraith, the former deputy chief of

the U.N. mission in Afghanistan. ``Nobody put the brakes on.

U.S. taxpayers spent hundreds of millions of dollars on a

fraudulent election.'' Galbraith, a deputy to the senior U.N.

official in Afghanistan, was fired last month after

protesting fraud in the elections.

As of April 2009, the U.N. spent $72.4 million supporting

the electoral commission with $56.7 million coming from the

U.S. Agency for International Development. The Special

Inspector General for Afghanistan Reconstruction states that

the United States provided at least $263 million in funding

for the election.

In one instance, the United Nations Development Program

paid $6.8 million for transportation costs in areas where no

U.N. officials were present. Overall the audits found that

U.N. monitoring of U.S. taxpayer funds was ``seriously

inadequate.''

U.N. Contribution: Monitoring nuclear programs in North

Korea and Iran.

Response: In 2002, the North Korean government used United

Nations Development Program, UNDP, aid to purchase

conventional arms, ballistic missiles. It also transferred

millions of dollars in cash to the government of North Korea

with no oversight of how the money was spent.

In September 2009, North Korea announced to the United

Nations Security Council that it was almost complete in

``weaponizing'' nuclear materials from its nuclear reactor.

Last week, North Korea announced the processing was complete.

As of this morning, Iran had rejected the U.N. offer to

send enriched uranium out of the country to prevent it from

developing nuclear weapons.

U.N. Contribution: Funding 17 U.N. Peacekeeping Operations,

including those in Haiti, Liberia, Lebanon, Darfur and the

Democratic Republic of Congo.

Response: U.N. Peacekeeping operations plagued by rape and

sexual exploitation of refugees--In 1994, a draft U.N. report

was leaked detailing how peacekeepers in Morocco, Pakistan,

Uruguay, Tunis, South Africa and Nepal were involved in 68

cases of rape, prostitution and pedophilia. The report also

stated that the investigation into these cases is being

undermined by bribery and witness intimidation by U.N.

personnel.

In 2006, it was reported that peacekeepers in Haiti and

Liberia were involved in sexual exploitation of refugees.

In 2007, leaked reports indicate the U.N. has caught 200

peacekeepers for sex offenses in the past three years ranging

from rape to assault on minors. In all of these cases, there

is no known evidence of an offending U.N. peacekeeper being

prosecuted.

Just this month, Human Rights Watch reported that Congolese

armed forces, supported by U.N. peacekeepers in the eastern

Democratic Republic of Congo have brutally killed hundreds of

civilians and committed widespread rape in the past three

months in a military operation backed by the United Nations.

Most of the victims were women, children, and the elderly.

Some were decapitated. Others were chopped to death by

machete, beaten to death with clubs, or shot as they tried to

flee.

The U.N. peacekeeping mission provides substantial

operational and logistics support to the soldiers, including

military firepower, transport, rations, and fuel.

The attacking Congolese soldiers made no distinction

between combatants and civilians, shooting many at close

range or chopping their victims to death with machetes. In

one of the hamlets, Katanda, Congolese army soldiers

decapitated four young men, cut off their arms, and then

threw their heads and limbs 20 meters away from their bodies.

The soldiers then raped 16 women and girls, including a 12-

year-old girl, later killing four of them.

The U.S. now pays 27 percent of all U.N. peacekeeping

operations. Reducing our contribution to these wasteful

efforts could help ensure that U.N. peacekeepers are not

funding widespread rape and exploitation of refugees.

U.N. Contribution: Compiling forecasts of global

agricultural production, identifying areas of likely famine

and risk of severe hunger, to facilitate emergency food

assistance (FAO).

Response: The FAO (Food and Agriculture Organization) is

currently hosting a U.N. food summit in Rome, where the

opening speaker is Zimbabwe President Robert Mugabe. Mugabe

is barred from travel to most Western countries because of

his atrocious human rights record, but receives an exception

for U.N. sponsored events. No G-8 leader attended the event

save the Prime Minister of Italy, the host nation.

``The meeting was branded a failure within a couple of

hours of its start after the 192 participating countries

unanimously rebuffed the United Nations' appeal for

commitments of billions of dollars in yearly aid to develop

agriculture in poor nations.''

The U.N. Environment Program spends over $1 billion

annually on global warming initiatives (and weighs in on its

effect on agriculture) but there is almost no auditing or

oversight being conducted. The U.N. Environment program has

one auditor and one assistant to oversee its operations.

According to the task force it would take 17 years for the

auditor to oversee just the high-risk areas already

identified in UNEP's work.

U.N. Contribution: Coordinating tsunami and earthquake

relief projects in Indonesia and Pakistan (U.N. Secretariat/

Mr. President, the majority whip is a formidable orator and he is appreciated in lots of ways. We work together on subcommittees on the Judiciary Committee. I have a fondness for him. Although one area he did not agree to work with me is to pay for it.

Never have I said I don't want us to do this for our veterans. Not once. The reason we are on the floor, the only reason we are on the floor having this debate is because of my hold; otherwise, we would never have gotten here to have the debate which I think is valuable for the people in this country.

But there has to come a time--every time I offer an amendment on this floor is never a good time--to start making our choices. That is what we hear all the time. Over 600 times in the last 4\1/2\ years, it is never a good time to start making hard choices. That is just what we heard.

The Senator from Illinois referenced Congo. Just this month the Congolese army, with the assistance of the United Nations, slaughtered a bunch of people. And we are supposed to continue?

I put two other things out there. Under Federal law, the Accountability and Transparency Act, the United Nations is required to tell the American people how our money is spent because the State Department is required to find it out and put it online. They have refused to do it. So we have no idea what it is.

Two years ago in the Foreign Ops bill, an amendment was agreed to by 100 Senators that there would be transparency. Our money going to the United Nations would be conditioned on the fact that the United Nations would be transparent on how it was spent. That was voted 100 to 0 in the Senate.

Guess what happened on the way to the bank coming out of the conference committee. It was eliminated. So now we send over $5 billion directly, $5.2 billion, plus billions more through USAID through the United Nations, and we do not have any idea how it is spent.

What we do know is that the United Nations is fiscally and morally bankrupt. It is loaded with fraud, loaded with duplication, and loaded with excess.

It would be a wonderful thing to send the United Nations a wonderful fire shot across the bow that they have to start being accountable for the dollars that the American taxpayer, that this little girl is sending them out of her future every year. It would be a wonderful thing for us to say that.

It is unfortunate, every time when we get down to the point where we have to make a hard choice, we always choose not to make the hard choice. That spells disaster for our country, and it also spells a total lack of leadership on our part to recognize what the real problems are that are confronting this country.

Our veterans deserve us to take care of them. I am for that. Our children deserve for us to do it in a way that protects their future-- the very thing for which our veterans serve.

Unfortunately, we will not do that with this amendment or any other time until the American people decide they have had enough of the careerism, the elitism, the lack of integrity, the lack of courage that is so often represented in the votes we cast in this body.

I reserve the remainder of my time, and I yield in my absence any time the Senator from North Carolina wishes to take from my time.

Mr. President, I listened very carefully to the chairman of the Veterans' Committee. He misses one major point: If, in fact, we don't send the money to the U.N., we will have money to pay for the veterans--if we don't send the money.

That is what this amendment does. It precludes that money from going from the State Department's budget to the U.N. I admit it is fungible, but that is money we will not send to something that is low priority, that is wasteful, that is nontransparent, and that the vast majority of Americans agree we get very little value from when we send that money to the U.N.

I also take issue with my friend's words that it is time. I think the chairman will agree that this bill was not noticed until October 28. That is when this bill was noticed. When the bill was noticed, the next day a unanimous consent request came through to say pass this without any debate, without any discussion, pass it through the Senate. I said, no, we ought to have a debate. At that time, we offered the Veterans' Committee a list of some 20 options of things that are lower priority than helping our veterans. They were rejected out of hand, which is the problem I have been describing on the floor earlier.

Every time it comes down to making a choice, the majority of this body chooses not to make a choice, not to choose a priority, not to do what we get paid to do, not to do what is in the best interests of the Nation. They choose to not choose. But by choosing not to choose priorities, we still choose, because what we choose is to take the money from our children. We choose to lower the standard of living of our children.

I want to tell you about veterans with whom I have spoken. I have had a lot of calls on this, because how dare somebody hold up a veterans bill before Veterans Day. The vast majority of the calls say we think you ought to support veterans, but we also think you ought to pay for it. Our country can't keep doing what we are going to do. So on the last appropriations bill through this body, I gave you an opportunity. We have heard three Senators today say there is no price we should not give to support our veterans. Direct quotes. ``No price is too great''? There is one price that is too great, because all three of those Senators who spoke those words refused to give up their earmarks to pay for veterans in the VA-MILCON bill. They all voted against paying for it in the MILCON bill by eliminating the unrequested items they had earmarked for them in the VA-MILCON bill. So, yes, there is a price that is too great--the price of helping yourself and your own constituency on a parochial basis and putting that ahead of the best interests for our veterans. So the words ``there is not a price too great'' ring hollow. We put our parochialism ahead of it.

I ask unanimous consent to add Senators Inhofe and Burr as cosponsors of my amendment.

Mr. President, as we talk about this debate, as my colleagues know me very well, the debate isn't about veterans; it is not about the veterans bill. It is about reestablishing some fiscal sanity in Washington of which we have none. This bill here--the health care bill that was released last night--over the next 10 years will spend $2.5 trillion. That is what it will spend. We don't know the accuracy of CBO. They certainly haven't done very well in the past on health care, as to whether it saves money. What we do know is that it doesn't cut the cost of health care, which is the problem. It transfers $2.5 trillion under the guise of the control of the Federal Government, which is not efficient.

I have not heard one colleague defend the United Nations. Nobody will get up in this body and defend the atrocities, the waste, and the fraud of the U.N. Nobody will say that. But those same people who actually agree with it but won't do anything about it will vote against this amendment. They will vote against the amendment. They won't defend what has very accurately been described as the behavior, the lack of fiscal sanity, the fraud and theft, the rape and pillage by the peacekeepers, the lack of oversight, and the total lack of transparency. They won't defend that with their words, but they will defend it with their vote. They are going to absolutely defend it with their vote. Once again, they are going to refuse to make the hard choice. Most of them listening to this agree, but it is the wink and nod that we play around this body. They know the U.N. is a big mess. They know it is a big problem. But they won't do anything to fix it. They will vote for complete transparency and vote to condition our funds on transparency, and when they get to conference, they will take it out. They will look good on the outside, but the inside of the cup will be absolutely filthy.

When is it we will see a turnaround in Washington that will match the courage of our veterans and meet the expectation of the citizens of this country? When is that going to happen? I will tell you when it is going to happen: It is going to happen when the Chinese start selling our bonds or quit buying them. That is when it will happen. Then we are not going to be able to make those decisions based on our choice. They are going to be dictated to us. They are going to be rammed down our throats.

The fact is that $3.7 billion is a lot of money. It is $3,700 million. That is hard to think about when you start talking about billions. Yet we are going to pass it. By the way, this bill that is so critical to get passed right now has no money in it for veterans for this process. Would the chairman agree with that? There is no money there now? It is not going to happen until a year from now, unless we put it in some supplemental program between now and next September 30. So what we are promising isn't going to come due, because we turned down an amendment on the VA-MILCON bill that would have allowed money to be available as soon as the VA-MILCON bill passed the conference committee and the President signs it.

How hollow does that sound? We claim one thing but our actions are totally different. And the VA says, by the way--at least intimated-- once they get this bill and the money, it will take at least 180 days to implement it. So add 18 months to right now to when our first veterans will see the benefit, especially the caregivers. And we could have, with the VA-MILCON amendment I offered--which was rejected--made that happen next month--at least the planning in the first 6 months of that--so that by March or April caregivers could actually start receiving this money.

I have tremendous worry for our Nation. If you open your eyes, you will too, because we cannot keep doing what we are doing.

Just some statistics. These are accurate, based on GAO, OMB, and Congressional Budget Office:

Ending September 30, not counting the supplemental, the Federal Government spent $33,880 for every household in this country. But we only collected an average of $18,000 per family. We borrowed, per family, $15,603 last year. Those numbers are going to be bigger next year. We are going to spend more, we are going to borrow more, and we are going to collect less. What is the implication of that? What is the implication of borrowing money we don't have and spending it on things that are not a priority, such as caring for veterans? The implication is that it will come to an abrupt halt in a very damaging and painful way--maybe not for us in this body but certainly for my children and my grandchildren, and certainly for those who follow us.

There is a bigger worry than the financial aspect of it. It is that we are losing, as we do this, the very integral part of what makes our Nation great. It is called ``sacrifice.'' That is why we honor our veterans. It is because they sacrifice, they put themselves on the line. Our heritage has been, from the founding of this country, to the very people who risk their lives and fortunes to initiate this country--the heritage has been of one generation sacrificing so the next generation can have greater opportunity and greater freedom and greater liberty.

As I said earlier, when we come back and get down to the actual voting on this amendment, most people will say: We can't do that. It is not time to make a hard choice.

I want to tell you, those veterans who have closed-head trauma made a hard choice. Those veterans who lost their lives and family made a hard choice. Those veterans who have severe disability and their families made a hard choice.

In a little while, we are going to dishonor that, because we are going to refuse to make a hard choice and rationalize in a way that it isn't going to do any good or make any difference, and we are not going to even attempt to get the out-of-control spending in Washington under control. We will reject the notion that you can, in fact, look at something and see what it is like, such as the corruption, such as the waste, such as the rape and pillaging of the U.N. peacekeeping troops, and we are going to say that is not important, and what is important is that we keep doing it the way we have always done it. We will continue to do it the way we have always done it.

The way we have always done it for the past 20 years does not honor what built this country. It doesn't honor making that sacrifice. It does not honor saying I will make a tough vote, even though the administration doesn't want me to make this vote. I will make a vote that is right for the country, right for the future, right for our kids and our grandkids. I will make that vote.

We will not see that today. We will not see the courage mustered up to choose between veterans and a sloppy, ill-run organization into which this country pours billions of dollars every year and continues unabated and uncontrolled and without oversight because we refuse to make a choice.

So my colleagues get a choice. Here is the choice: Ignore with a blind eye the absolute tragedies that are going on at the United Nations, the absolute waste, the incompetency, the favoritism, the theft that is going on and say you did something good for veterans.

The fact is, the reason our veterans have such severe injuries is because they protect our liberty, protect our freedom, and protect our future. We are not going to choose that today. We are going to choose the opposite. We are going to do the status quo. We are going to say this amendment does not make sense.

When will we muster the courage to make a real choice, to go out and defend that veterans are worth more than the waste at the United Nations? We will not make the choice because we know we can vote against this amendment and still tell the veterans we did it and we don't have to speak to our grandchildren and children. We will be gone. We will be out of here.

When their standard of living is 35 percent below the standard of living we experience today--by the way, that is what is forecast as the government takes over 40 percent of the GDP of this country and as we end up with interest costs in excess of $1 trillion a year just to fund the excesses of what we are doing today, which is less than 5 years away, and we will be spending $1 trillion a year on interest--we will have no recollection of this vote. We will have no recriminations against us. We will have just voted and said that is

another amendment to try to make us make a choice, but we refuse to make one.

By voting against this amendment, you are defending the audacity, corruptness, inefficiency, and fraudulent behavior of the United Nations. That is what you are doing. Nothing can be cut. Have you noticed that? Nothing is not important to the politicians of this city. Everybody has an interest group. Oh, we can't go against that. That is an absolute formula for disaster for our country.

I wish to enter into the Record some additional information on the United Nations. I only touched the surface on the amount of outlandish things that have gone on in the United Nations. I did not mention Oil for Food, billions of dollars, and of the people who took all that money, none of them got prosecuted. The U.N. Headquarters renovation is going to cost $2 billion. It should cost about $800 million. I did not talk about that or the lack of transparency in terms of the State Department, in terms of reporting how our money is spent at the United Nations.

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

Mr. President, I will finish and give the chairman the last word. What the chairman and his committee are attempting to do is honorable. It is the right thing to do to help our veterans and to secure and help those who are helping our veterans. I agree. However, I don't agree that we ought to do that on the backs of our children. I think we ought to do it on our backs. We ought to carry that load. Our children and our grandchildren should not have to carry that load. We ought to be forced to make the sacrifices to pay for the sacrifices they have made for us. This bill does not do that.

This bill takes the easy route. It says you do not have to pay for it, it is not required. There is not anything we can get rid of, after I offered all these options to the committee in terms of what they could get rid of that would pay for it.

If we don't pay for it from what I offered, then get rid of our own earmarks, the things that make us look good. We chose to keep our earmarks and charge it to our grandkids. It is a wonderful choice and a wonderful thing for the American people to see.

On this vote, they are going to see three things. They are going to see all the people who voted to keep their earmarks vote against this amendment. The first thing they are going to say is: My earmarks are more important than paying for veterans, caregivers, and everything else expanded in this bill.

The second thing they are going to see is that we do not have the courage to take on fraud, waste and abuse and lack of transparency at the United Nations. They are going to see us fail to live up to the expectations they have for us.

Everybody in America knows we are in trouble financially. They know the Federal Government is too big. They know the Federal Government is inefficient. They know we can do better. They are just wondering when we are going to start. When will it start? When will be the first time we make a hard choice? I regret it is not going to be on this bill because it is symbolic. If there ever was a bill on which we should start to make the hard choices, it should be on a bill that honors and takes care of the people who have made hard choices for us, the people who have sacrificed their lives and their future and their families for us.

The third thing, regrettably, that they are going to see is that we are going to continue to play the game the way it has been played: Get the votes to defeat the amendment; we will take a little bit of heat; maybe somebody will notice. I will guarantee you, 20 years from now, our kids are going to notice, our grandkids are going to notice.

One final thought. If you are under 25 in this country, pay attention to me right now. If you are under 25--there are 103 million of you. Twenty years from now, you and your children will each be responsible for $1,919,000 worth of debt of this country for which you will have gotten no benefit--none. The cost to carry that will be about $70,000. That is not per family, that is per individual. The cost to carry that will be about $70,000 a year before you pay your first tax.

Ask yourself if you think we are doing a good job when we are going to take away your ability to get a college education, we are going to take away your ability to educate your children, when we are going to take away your ability to own a home, and we are going to take away your ability to have the capital formation to create jobs in this country. Watch and see. That number is going to grow every time we do something like this without paying for it, without offsets, without getting rid of something less important.

I yield back the time and yield the remainder of my time to the chairman of the committee.