costs, we see even though they're providing universal coverage in these other countries, their costs are much lower than ours. and if we look further at the quality of health care outcomes, quite an interesting story emerges. because those countries have universal care, lower costs, and if you look at quality outcomes, they do better than we do. on preventable deaths, which may be, according to the commonwealth fund -- which is very distinguished, nonpartisa nonpartisan -- they looked at preventable deaths around the world. they found the united states came in 19th. but other countries that have much lower exposes have universal -- lower costs and have universal coverage -- for example, france and japan -- are ranked one and

two. with much lower cost and universal coverage, they're getting better results. and some don't even want to debate going to health care? i mean, they're going to have a tall order to explain why they don't even want to discuss it. on infant mortality, the united states ranked 22nd. again, according to the commonwealth fund. again, countries that have universal coverage, much lower costs than we do, ranked number one, japan. france was number five. germany was number nine. and from my earlier chart, you will remember each of those countries has universal coverage and much lower costs than we do, and yet they are getting on these metrics better outcomes than we are. and it doesn't stop there. here's life expectancy.

the united states ranked 24th. this is according to the oecd, the international scorekeeper. and again, japan, switzerland, france, universal coverage, much lower costs, still ranked much higher than we did on that metric. japan, universal coverage, much lower costs than we do. in fact, half as much as ours, and yet they were number one. switzerland, number two. universal coverage, much lower costs than we do, and yet they ranked number two. france, universal coverage. much lower costs, they rank sixth in the world. you know, it would seem to me we ought to look to evidence and evidence shows us there is a better way, and that's what this legislation seeks to find. it seeks to find a better way to expand coverage, to improve

quality, and to contain exploding costs. and the key elements of this senate health care reform plan are these: one, it reduces both short and long-term deficits. i noticed in one of the newspapers circulated on the hill today a full-page ad asking how can senator conrad, who is a deficit hawk, be for this bill? well, because i've read the c.b.o. analysis, the congressional budget office analysis that says clearly and unequivocally this bill lowers the deficit, lowers it by by $130 billion over the first ten years. it lowers it by $650 billion over the second ten years, according to the congressional budget office. so when somebody asks how can a deficit hawk be like senator conrad -- like senator conrad be for this bill, it's because this bill lowers the deficit. that's not my analysis.

that's the official analysis of the congressional budget office that is nonpartisan. mr. president, this bill also expands coverage to 94% of the american people, promotes choice and competition, reforms the insurance market and improves the quality of care. all of these are at the heart of what reform must be mr. president, the senate health plan reduces short and long-term deficits, extends medicare solvency. medicare is going to go broke in eight years. this bill extends the life of medicare by four to five years. extends the solvency of medicare by four to five years. it includes reforms to improve delivery of care and reduces costs. it curbs overpayments to

medicare advantage plans. some medicare advantage plans are now costing 150% of traditional fee-for-service medicare. medicare advantage was started on the basis it would save money. in fact, it was initially capped at 97% of traditional fee-for-service medicare. it was supposed to save money. now there are medicare advantage plans that cost 150% of traditional fee-for-service medicare. not saving money. it's costing much more money. and it will break medicare if we don't reform it. that is clear. this bill also creates an independent medicare advisory board to make recommendations on how we can have further savings to extend further the solvency

of medicare. it also includes an excise tax on insurers offering cadillac plans. virtually every analyst that came before the finance committee said one of the most important things we could do was to start with a levy on cadillac health insurance plans could reduce overutilization and to begin to control the exploding costs. mr. president, when i say this bill reduces the deficit, that is not my assertion or the work of the senate budget committee. that is the judgment of the official scorekeeper here, the nonpartisan congressional budget office, and here is a wage from their report and it shows very clearly from 2010-2019, this legislation reduces the deficit by $130 billion.

i've heard colleagues come to the floor and give all kinds of speeches about how this increases the deficit. they've got every right to come here and make up any numbers they want to make up. they can make any claim they want, but let's be clear the official analysis of this bill by the agency that we have all empowered to give us objective analysis has con includedded that this bill reduces the deficit by $130 billion over the first ten years and $650 billion over the second ten years. mr. president, the congressional budget office on the senate health plan rediewg long-term deficits, and i quote -- "c.b.o. expects that the bill, if

enacted, would reduce federal budget deficits over the ensuing decade beyond 2019 relative to those projected under the current law with a total effect during that decade that is in a broad range of .25% of gross domestic product." gross domestic product over that period is projected to be be $260 trillion. .25% of $260 trillion is is $650 billion. c.b.o. anticipates that the legislation would probably continue to reduce budget deficits relative to those under current law in subsequent decades." in other words, it would continue to reduce deficits beyond the first 20 years. mr. president, the excise tax

that virtually every analyst has said needs to be part of a package if you're going to be serious about controlling the explosion of costs will target plans that have a value of more than $23,000 a year. the average premium in 2013 is projected to be $15,740. so these cadillac plans are plans that would have a value of more than $23,000 a year. there are very few people in the country who have plans of that value today, and there will be very few that will have values -- have plans of that value in 2013. the senate health care plan also expands coverage. according to the congressional budget office, it covers 94% of the american people by building on our existing employer-based system. it creates state-based exchanges for individuals and small

businesses. it provides tax credits to help individuals and small businesses buy insurance. in fact, mr. president, there are more than $400 billion of tack credits here. somebody -- of tax credits here. somebody said well, this is a big tax increase, a big tax increase. well, they must have left out the $400 billion of tax credits. they must not have gotten to that page in the bill. and it expands medicaid eligibility with assistance to states so they are able to afford it. mr. president, the senate health plan also promotes choice and competition. it creates a public option to compete with private plans, but not one based on medicare levels of reimbursement. i think many of my colleagues know i strongly resisted a public option tied to medicare levels of reimbursement because that would work a real hardship in my state. but in this plan, there is no

tie of public option to medicare levels of reimbursement. and states can opt out. it also provides seed money for nonprofit cooperatives, member-run, member-controlled cooperatives to compete with private plans. mr. president, this chart shows the medicare reimbursement per enrollee for 2006, and you can see new york was getting nearly nearly $10,000. north dakota, $6,000. that is the kind of disparity that exists in medicare reimbursement. it is even more dramatic if you look at institution to institution. in fact, for many years, i was showing a hospital in devil's lake, north dakota, mercy hospital that would get one half as much as lady of mercy hospital in new york city to treat the exact same illnesses,

one half as much, and that's all based on formulas, based on historic costs. that's why many of us believe it would be unfair to tie public option to medicare levels of reimbursement. that disparity across the country would work an extreme hardship on low reimbursement states like mine. mr. president, the cooperative plan allows for not-for-profit co-ops to provide affordable, accountable transparent alternative to private insurance. the mission is to provide best value for consumer members. it could operate at the state, regional, or national level. they are self-governed by members with an elected board, not controlled by the federal government. subject to the same state and federal rules and regulations as private plans. and there would be $6 billion in start-up funding for the capitalization by the federal government, and that would be the end of the federal

government role. mr. president, the senate plan also reforms the insurance market. it prohibits insurers from denying coverage for pre-existing conditions. prohibits insuressers from rescinding coverage when people become sick after paying premiums for years. it bans insurers from lifetime caps and unreasonable annual limits on health care benefits, and it prevents insurers from charging more based on health status. mr. president, this plan also improves the quality of care. it covers preventative services. provides incentives for healthy lifestyles. promotes adoption of best practices, in comparative effectiveness research, and includes delivery system reforms to encourage quality over quantity of care. mr. president, when we look at the major reforms that are in this bill on the delivery system

and compare them to the house, we see the senate has accountable care organizations, the house a pilot. both have primary care payment bonuses. both have readmissions reforms. only the senate has hospital value-based purchasing. both have comparative effectiveness research. both have c.m.s. innovation centers. only the senate has an independent medicare advisory board, and only the senate has a full platform for bundling. the house just has a pilot. mr. president, debunking the myths. there is no government takeover of health care here. the public option, according to c.b.o., would get 2% of the american people, 2%. that's hardly a government takeover, and there is no tying of the public option to medicare

levels of reimbursement. there is no cut in the guaranteed benefits for seniors. there is no coverage for illegal immigrants. there are no death panels. and there is no expansion of federal funding for abortion services. mr. president, to conclude, if we look at the senate democratic plan and the only republican plan and compare them, the senate democratic plan contains delivery system reforms. there are none in the republican proposal. the senate proposal, democratic proposal, reduces the number of uninsured by 31 million people. the republican plan makes no progress on that front. the senate democratic plan bans preexisting conditions an rescissions of coverage and health status rating and

lifetime benefit limits. the republican plan has no similar provisions. the senate democratic plan improves rural medicare reimbursement. the republican plan does not. the senate -- the presiding officer: the senator's time has expired. mr. conrad: i would ask for 30 seconds. the presiding officer: without objection. mr. conrad: the senate democratic plan extends medicare solvency by four years, the house republican plan has no extension of medicare solvency. finally, the senate democratic plan reduces the deficit according to the c.b.o. b by $130 billion. twice as much as the republican plan from the house. i thank the chair. i thank my colleagues. a senator: mr. president? the presiding officer: the republican deputy leader. mr. kyl: thank you. mr. president, we're going to focus for the next hour on perhaps one of the most

pernicious aspects of leader reid's bill. the fact that it cuts medicare by almost $500 -- half of a trillion dollars, almos almost $500 billion in medicare cuts. there are a lot of seniors in my state of arizona. and in the states represented by my other republican colleagues here. and those seniors are scared of these cuts. it's not because of anything the republicans have said to try to scare them. they've simply become aware of what's in these bills. and by these bills, i'm talking about both the senate bill, offered by the majority leader, and the house bill, which are the two bills that would presumably try to be reconciled in conference. and our seniors have been told that under both bills, their benefits are going to be cut by

about $500 billion, and that is enough to scare them. and, in fact, all of america is concerned about this. a recent gla "usa today gallup"l shows that 61% of seniors disagree with cutting medicare reform. despite that they have moved ahead to pay for the new health insurance programs. they're suchly not listening to what americans have to say about -- simply not listening to what americans have to say about this. if democratic leaders have their way, hundreds of billions of dollars will be slashed from hospitals that treat seniors, from the medicare advantage program, from the nursing home care, home health care, hospice care. medicare faces a severe challenge, including a whopping $38 trillion in unfunded liabilities and

insolvency by the year 2017. that's almost incomprehensible. in just a few short years years, $38 trillion in unfunded liabilities and insolvency. obviously seniors want us to fix that problem rather than raiding medicare to pay for a new health care program. and they want to preserve medicare advantage. i receive letters from worried seniors every day about the plan to cut medicare advantage, which is a popular program in arizona. medicare advantage is the opportunity we've given seniors to enroll in a private insurance company to help them receive medicare benefits. and what these private insurance companies do is to make a more attractive program by adding some additional benefits to the basic set of benefits that are promised under medicare. and what our seniors are telling

us are that these are very important benefits to them. things like vision a care, hearing. i mean, now that i'm getting a little bit older, i can tell you that both my vision an hearing is starting to go and i'd like to have that kind of benefit. dental benefits, preventive screenings, free flu shots, home care for chronic illnesses, prescription drug management tools, wellness programs, personal care, and durable medical equipment, very important for seniors. physical fitness programs one of which has the great name called the silver sneakers program, and the seniors are very supportive of this because it keeps them physically fit, which, of course, is what we should be doing. i get letters an phone calls from my constituents an they're sharing their anxieties about losing their benefits, losing prescription drug coverage about, the overall decline in the quality of care they understand will occur when their doctors' payments are cut, when

all of the other cuts under medicare that my colleagues are going to discuss in a moment finely hit. they know it will impact their care. they don't like the government bureaucrats getting between them and their physician when it comes to their health care. let me read portions of three letters from constituents and i will yield to my colleagues here. a constituent from surprise arizona writes, "dear senator kyl. please fight the cuts to medicare advantage. i'm on the social security disability. the medicare advantage i have has literally been a lifesaver for me. i cannot afford to lose the coverage that includes prescription drugs. i need your help on this. " two medicare beneficiaries, a husband and wife from mesa, arizona, write, "we believe our health is our responsibility and we have a right to make our decisions regarding our health. we do not need our government to take actions.

we do not need a third party who has never met us and makings decisions regarding our medicare and we do not want to lose our medicare h.m.o.'s," a constituent from sun city west, arizona, a world war ii veteran, wrote a very powerful letter of how medicare advantage improved his life and his wife. he wrote, as a b-17 pilot, i flew 52 combat missions out of england and won five air medals. when we moved to arizona to be near our children, i visited the local v.a. hospital to find out that i had a $50 co-pay for each visit. i never saw a physician, just an assistant. i purchased the medicare advantage, i only receive $33 a month on social security. fortunately here in arizona my wife and i were both able to

sign up for midisun, with no monthly payment and simple $10 or $20 co-pays, that made it possible for us to purchase a home. with the health care reform being considered, we understand that advantage plans will be reduced or eliminated. what happened to if i like my insurance, i can keep it? end of quote. well, it's a good question for my constituent. and, of course, he's exactly right. when the promise was made if you like your insurance, you get to keep it, unfortunately that's not the way this legislation works, and, as a result, a lot of the benefits they're currently receiving, for example for medicare, would be cut or eliminated. my constituents are right to be wary of cuts to their medicare advantage. they depend on it and realize that you can't cut half a trillion dollars for medicare

without adversely affecting their health care. a senator: if the senator would yield to me when before he closes. mr. kyl: i would be happy to yield to my friend. mr. wicker: i think it is important to understand. there are some differences between the bills. the "help" bill, the finance committee bill, and the bill from the house of representatives. in each and every case, the proposals put forward by the democrats do have a half a trillion dollar cut in medicare, and, indeed, as the senator pointed out, these involve cuts to hospitals, to medicare advantage, medicare cuts to nursing homes, to home health and to hospice. there's just no question about that. and i appreciate the senator bringing some information to the public and to the senate about concerns by his constituents. in the previous hour i heard a

senator from the other side of the aisle talk about scare tactics that republicans would be putting forward during the coming weeks of this debate. of course, you've read letters from your constituents outlining why the people of arizona are legitimately fearful for -- for the coverage that they have enjoyed. but i -- i would tell my colleagues, and i would say this, mr. president, that the opposition to these medicare cuts has come in a bipartisan way. and we heard a great deal about that from our friends at the other end of the building when the house of representatives was talking about this. the president of the blue dog democrats, a senior democrat who has worked to try to make this palatable to people in his

constituency. mike ross, a democrat from arkansas, had this to say about these medicare cuts, and i quote -- "with more than $400 billion in cuts to medicare, it would force many of our rural hospitals to close. providing less access and care for our seniors." now less than 12 days ago representative ross from arkansas said this. his constituency is very much like mine in mississippi, and i can assure the senators that a great number of our hospitals in mississippi and throughout the country are -- are rural and, no doubt in arizona too. so there's a very real concern and -- and the gentleman from arkansas flatly says that it could force many of these rural hospitals to close. now representative larry kasell of north carolina said this, from the day i announced my

candidacy for this office, i promise to protect medicare. i gave my word i wouldn't cut it and i intend to keep my promise. and representative i represental concluded that the only way to keep that promise was to vote no on this legislation. representative michael mcmahon of new york said, medicare advantage, which serves approximately 40% of my seniors on medicare, would be cut dramatically. this is not a republican scare tactic. this is a flat statement by an elected democrat from the state of new york and the northeastern part of our country. one of the larger states. but -- but he said flatly that medicare advantage would be cut for 40% of his seniors, and he voted no on that basis. representative ike skeleton, the

chairman of the armed services committee said, and i quote -- "the proposed reductions to medicare reimbursement could further squeeze the budgets of rural health care providers." he goes on to say i also oppose the creation of a new government-run public option and continue to have serious concerns about its potential unintended consequences for missourians who have private insurance plans they like. and, of course, we know that this reid bill before us also has the government-run option. and, finally, to quote representative rick voucher, another senior democrat from virginia. he said, "i also intend to oppose the bill because my concern that a government-operated health insurance plan could place at risk the survival of our region's hospitals."

i'm concerned and i'm determined to protect the rural health care that we have in the state of mississippi, and that we have in these districts that are represented by -- by these comments. and so i just wanted to jump in now before the senator from arizona concludes his portion of the initial remarks and say that the concerns are not only coming from republicans, they're coming from actuaries, they're coming from people who have analyzed this bill, and they're coming from -- from democrats who have read the bill, who understand its meaning, and understand that these cuts to medicare are real and they're hurtful. and i yield back to the gentleman. mr. kyl: mr. president, the senator from mississippi is exactly right. and it's not just members of the house and members of the senate, republicans and democrats, and senior citizens in the state of arizona. there are some other third party sources i'll cite three.

the centers for medicare and medicaid services, that's c.m.s., that's the outfit that runs medicare, they confirm that medicare cuts will compromise the care that seniors receive. "the washington post" newspaper, how about that for a third party source sal -- validating summer rises a support in an article "bill would reduce senior care," saying and i'm quoting, a plan to slash more than $500 billion from future medicare spending, one of the biggest spending for president obama's overhaul would sharply reduce benefits for some senior citizens and could jeopardize access to care for millions of others. end of quote. and then "politico," a capitol hill newspaper, reported by 2014, enrollment in medicare advantage would drop from $13.00 -- 13.2 million to 4.7 million because of less generous

packages. looking at my colleague's chart, medicare advantage, which i spoke about and my constituents had written to me about, the concern there is that people now enrolled, 13.2 million are going to be reduced to 4.7 million because the reductions in the benefits are simply no longer sufficient incentive for them to enroll in that program. and, of course, that's what the pro-government-run health care folks want to happen. they're all for a public company competing with private insurance companies in the market for most folks, but when it comes to medicare, they don't want the private companies competing who provide medicare advantage care, they don't want them competeing with the government program. un, they're going to get their way. going to go from 13.2 million down to #.7 million. that's a lot of senior citizens

who are going to lose their medicare advantage coverage. i'm going to conclude by confirming what the senator from mississippi said. it's not just representatives in the house of representatives or senators who have sworn to help protect our constituents here, but it's third-party sources as well in the government and in the media who have confirmed the fact that this bill will cut benefits. and they'll certainly do it for senior citizens. we'll talk later about the republican ideas rather than identify a lot of us here. i'll just note that republicans have suggested a step-by-step approach to target specific exclusions to specific problems including things like medical liable reform, allowing residents to purchase insurance across state hraoeurpbgs association health plans which would help to reduce costs. most of our ideas are cost-free. they don't add a cent. they wouldn't cut medicare. they wouldn't diminish the

quality of care for anyone. but they have been rejected by our democratic colleagues. so i think we can do better. i would hope that my colleagues would agree that a place to start in this legislation is not to cut medicare. why would you want to cut medicare if the whole idea here is to provide greater opportunity for affordable and quality health care for american citizens? it makes absolutely no sense to me. let me yield to my colleague from idaho. a senator: thank you very much. i appreciate the senator from arizona and comments he made. i appreciate the opportunity to be here with my colleagues from mississippi and florida as well. mr. crapo: when the people in the united states talk about health care reform, what they're seeking is some way to control the punishing and skyrocketing increases year after year in health care insurance costs and medical costs and better access and quality of health care. yet, when this 2,074-page bill

that was crafted in secret for the last two or three weeks was finally revealed, that's hardly what we got. in fact, the reality is that this bill will drive up the cost of health care insurance and medical care in this country. it will increase taxes by hundreds of billions of dollars. it will cut medicare by hundreds of billions of dollars. it will grow the federal government by $2.4 trillion of new spending over a ten-year period. it will push the needy uninsured not into subsidized health care insurance, but into a failing entitlement program -- medicaid. it will impose a damaging unfunded mandate on the states that are already strapped financially. and it will leave millions of americans uninsured while creating probably the most enormous and massive extension of federal control over our economy that we've seen in our country, starting with the creation of a new federally owned and managed insurance company. well, today, as the senator from arizona has indicated, we're here to focus on the medicare

cuts aspect of this proposed legislation. the senate bill contains something in the neighborhood of $500 billion of cuts in medicare. the first one i want to focus on is the one that the senator from arizona has already identified and that is the medicare advantage cuts. the senate bill contains $118 billion in cuts to the medicare advantage program. let me just talk about that program for a minute. currently there are nearly 11 million seniors, as has been indicated, enrolled in medicare advantage. that represents about one out of four of all medicare beneficiaries in the united states. in my home state of idaho, there are more than 60,000 medicare advantage beneficiaries, which is about 27% of the population in idaho. in addition, this is an extremely popular program. a 2007 study reported very high overall satisfaction with the medicare advantage program. 84% of the medicare respondents said that they were happy with

their coverage, and 75% would recommend medicare advantage to their friends or family members. and yet, despite this, there are massive cuts coming forward in the bill. why would that be the case? i don't think most americans who are not on medicare recognize the difference between medicare generally or medicare advantage, but medicare advantage was a modification of the traditional medicare program that, frankly, was put into place -- i ask my colleague from arizona to comment on this. wasn't this put into place when the republicans were in control of the congress to try to help get market forces more engaged and involved in the administration of medicare benefits? mr. kyl: the answer to that is yes. the idea was that seniors were complaining a lot about the existing program, and for one thing, a lot of folks in rural areas were not receiving good and efficient and quick care

because they had to drive long distances, they couldn't find a doctor who would serve them, the hospitals couldn't take care of them, and so on. one of the things that republicans tried to figure out is how could we incent the insurance companies to put together pools of physicians in hospitals to go into these rural areas and take care of citizens that live there. the medicare advantage program was one of the ways in which that was done, and it's proved, as the senator said, to be very, very successful. mr. crapo: this is the point that i want to make. if you look at the federal entitlement program of medicare, the portion of medicare that truly does have some private-sector involvement where private-sector companies can come in and contract to provide the government's responsibilities under medicare, is the most popular of all medicare programs, the one that was growing. the one that was letting the private sector deliver the benefits. and one of the aspects of the medicare advantage program is that senior citizens on medicare

advantage actually get additional benefits beyond those traditional medicare benefits that those in the normal or standard medicare program don't get because the private-sector options have been able to identify ways to enhance and create opportunities for greater and stronger benefits. yet, those who do not want to have anything but a single-payer system, those who want to make sure that the government-provided health care is provided only by the government do not like the medicare advantage program. saopbd it's not -- and so it's not surprising that we see this level of cuts in this program. during the finance committee markup, the c.b.o. estimated that the value of extra benefits that medicare advantage plans provide will drop from $135 a month of extra benefits to $42 a month of extra benefits based on the cuts in the bill that we had before us then. let's put up this chart. the c.b.o. -- the congressional budget office -- director

elmendorf confirmed this during the markup. specifically, i asked him, so approximately half of the additional benefits would be lost to these current medicare advantage policyholders? and his answer was, "for those who would be enrolled otherwise, under the current law, yes." in other words, compared to current law, if the cuts put into place -- proposed are put into place, about half the benefits would be lost to these medicare advantage beneficiaries. we now have more detail on that. i'm sorry we don't have a bigger chart. we're going to have one for future parts of the debate. but if you can see the united states here, those states that are in the deep red are the ones that have cuts in kp-s of 50% -- in excess of 50% to their medicare advantage beneficiaries. those that are in the lighter red are between 25% and 50%. you'll notice those in the white -- there's only one, two, three, four, five states that are in the white -- are the ones that do not have a negative impact. 45 of the 50 states will see significant reductions in the medicare advantage benefits that

are provided to their constituencies. you just have to look at this map to see that it's a large percentage of those 45 states that are getting the cuts in excess of 50% of their benefits. a senator: would the gentleman yield for a question? mr. crapo: yes. mr. lemieux: i think i understand that you're saying that states that have these folks that are on medicare advantage now are going to have big reductions in the benefits that they receive. my understanding, this is flu shots, eyeglasses, hearing aid. as the senator from arizona said, programs to keep seniors in health. and these are programs that i understand that my folks in florida very much, you know, appreciate the medicare advantage program. we have more than 900,000 floridians who are on medicare advantage. so i want to make sure that i understand this correctly, is that under the proposal that's been put forward by senator reid, we're going to make substantial cuts to medicare

advantage and the benefit that medicare advantage provides? mr. crapo: that's absolutely right. and the way that i look at it is it's the extras. you'll hear some say medicare benefits aren't being cut by these proposals. that is a real stretch. but when you look at medicare advantage, it's an outright misrepresentation. because the benefits they get are vision benefits, dental benefits, the kinds of preventive medicine and the mammograms and the p.s.a. tests and the other types of things that we have found now help you to dramatically increase your health if you pursue these kinds of preventive medicine options are the ones that will be deprived through these benefits. a senator: if the senator would yield? i notice in senator lemieux's state of florida, that reduction, according to the c.b.o. map, would be 81%. unthinkable, drastic change in

the medicare advantage law. mr. wicker: in my area of the country, arkansas, for example, 40% reduction. my state of mississippi, a 51% reduction. and in our neighboring state of louisiana -- and these are just examples -- an 81% reduction, the same as the proposed reduction that this legislation we have before us would do for the state of florida. so i think it's important for our kwebt seus to under -- for our constituencies to understand the magnitude of these medicare advantage reductions. mr. crapo: true. taking other states as examples. california 68%. arkansas 40%. new york 69%. new mexico 65%. and the list goes on. the point here is these are cuts. the c.b.o. director has made it very clear that these will be benefits that medicare advantage holders will be losing.

mr. president, i'd like to move on to some of the other reductions in medicare, because the ingenious argument that is being made by the proponents of this bill is we can cut $500 billion out of medicaid and not impact anybody's benefits or the quality of the medical care that they are receiving. well, that's simply not true. because where do the other cuts, the nonmedicare advantage cuts come? they come from home health agencies -- they come from home health agencies, moss peus, skilled -- hospice, skilled nursing facilities and other providers in what is called the market basket. these cuts, you might say well, we can just continue to cut the compensation or the allocation of return for procedures and for health care provided in these medical provider services and not have any impact. but the reality is far from that. what will happen? well, i'm going to give you a couple of specific examples.

but in general, what happens is when a home health agency or a skilled nursing facility or a hospital receives these massive reductions of hundreds -- over $100 billion worth of cuts in these areas, they have to adjust somehow. and let me give you some examples. because the adjustment is this: in some cases providers simply stop taking medicare patients because they can no longer make a profit. and in that case, the medicare population loses access because they have fewer providers from which to choose. in other cases they reduce services or reduce employees. and, again, both the quality and the quantity of health care services to seniors is reduced. some examples: a few rao*ebgs ago i spoke to gary teeton about the impact of home health care cuts to his business. he described to me how bad the fiscal situation has already

become for home health care, hospice and other medical care providers in idaho. they have already lost 30% of their providers. let me repeat that. already nearly 30% of the home health care providers have gone out of business because we are squeezing them down so tight. and that included idaho's largest provider. the providers that are still in business are working under the same medicare reimbursement levels they received in 2001 eight years ago. and if the kinds of cuts that are contemplated by this legislation go into effect on top of the current reimbursement issues, the situation will get worse. gary said, he compared this to me with farmers in idaho. he said most farmers don't grow just one crop. he said those of us in the medicare and in the home skilled nursing facility, hospice and health agency facilities try to provide as many services as we can.

and all of this will get reduced. let me give you another example. robert van demere talked to me about the impact on skilled nursing facilities. skilled nursing facilities like the hospice facilities already face a budget challenge under recent c.m.s. rules restricting their compensation from the services they provide. the cuts they have already received, not counting what will come at them in this bill 100-fold more, have already cause add reduction in reimbursement in idaho by over $4 billion a year to skilled nursing facilities. he pointed tout me that in the nursing home world more than 70% of the expenses they have are labor, primarily nurses and nursing assistants. he said that when payment cuts like these occur, they can't just go to their buildings and take bricks out of it. what they have to do is to reduce their employment. that cuts employees. that cuts benefits and services to those who are there. so let me just make this clear.

first of all, these cuts are going it reduce jobs. and, secondly, they are going to be directly tied to the quality and number of staff who are there to provide care for those in the medicare system. mr. kyl: i ask my colleague will yield for this quick question. we've talked about the rationing of health care that is the ineffable result of these cuts -- inevitable result of these cuts in this bill. whawhen you reduce the amount of money that you reimburse hospitals and others with, they can't provide these services. some businesses gout of business so there are fewer entities providing the care. that means that it takes longer for patients to obtain the care where it is available and frequently they don't get as good a care because folks just can't take that much time to take care of them in that sense. would my colleague please talk a little bit about his concerns about the overall problem of

rationing that comes from the reductions in the benefits to providers -- and by the way, your chart -- i just want to say, it says "other medicare cuts to providers." we use that term "providers" around here as a shortcut term. but would my colleague explain in real -- what it really means to a 70-year-old woman in idaho. who is a provider and how important is that and what happens when you don't pay that provider so that provider is no longer available to take care of you? mr. crapo: thank you. and who are the providers? well, if this medicare beneficiary is in a skilled nursing facility, the provider is the facility itself, which i said we've already lost 30% of our facilities. and it's the nursing and the nurse assistants who are there to assist them and care for them. the bottom line you is simply cannot cut hundreds of billions of dollars out of these services and expect to provide the same level of access and quality and

available home -- or, health care. the same would be true if the care were being provided in a home setting, which a lot of the home-care services are compensated by medicare. or a hospital, which is there to provide in some of the most serious types of circumstances. but whatever it is, whether it is home hospice care or a skilled nursing facility or a hospital or what have you, what we see is a reduction of the number of facilities and personnel available, and that is nothing other than rationing. now, it is a different kind of rationing than will occur under some other parts of this bill where the government will actually get in the business of saying, what kind of health care you can get and at what time in your life you can get it, but it's a kind of rationing that simply forces the availability of health care down so far that the system itself rations it out. mr. lemieux: will the senator yield? mr. crapo: yes. mr. lemieux: i want to follow up on my colleague's point. with all of these cuts to

medicare, $464 billion in this, $192 billion in reductions to most services, $21 tbll cuts to hospitals serving low-income patients, $23 billion from other sources, it seems inevitable that seniors are going to have a lower quality of health care. and we were told by the president that if you liked your health care, you were going to be able to keep it. but it seems to me that we need to change that a little bit because under this proposal, you might be able to keep it unless you are real estate a senior. and that seniors are really going to have a diminished quality of health care under this proposal. is that correct? mr. crapo: the senator is absolutely correct, and i will comment on that and then conclude and turn some more time over for remarks to my colleagues from mississippi and florida. but that is exactly right. in fact, one of the most clear and obvious places in which this legislation violates the president's pledge that if you like what you have you can keep it is in medicare advantage

because, one out of four medicare beneficiaries in america will not be able to keep what they have and will see their benefits cut. there are also other parts of this bill that impact people outside of medicare in terms of the kind and quality and extent of health care insurance coverage that they have and expect that will be impacted. so it's going to impact beyond this. but this is about as clear a case as there is of violating that promise. a senator: before the gentleman leaves that subject matter, i wonder if i could interject this. mr. wicker: now, we've listed and my friend from idaho also has listed specific cuts under this legislation. hospitals, medicare advantage, cuts to nursing homes, cuts to home health and hospice. but also i think senators and americans need to understand that the reid bill also establishes a permanent board of

unelected members appointed by the administration, which in this case initially at least would be the obama administration, and they would dictate further savings under medicare, and this gets to the -- to my friend from arizona's question about rationing. it would dictate annual medicare cuts geared toward reducing medicare spending. now, these people are not going to be like us and accountable. they will not have to go back to their districts every two years or their states every six years. but they will have the unbelievable power under this legislation to dictate additional cuts that we know not of, and "the wall street journal" called this a rationing commission. and this ties right in with the

concerns that americans have had over the last two or three days about these recommendations with regard to mammograms. i have -- and i realize i'm intruding on the gentleman's time, but i have a letter here from a physician in mississippi who is fearful that this sort of rationing board is going to impose the requirement that mammograms not be given until after age 50, and he says, "my wife and i have two daughters who had breast cancer in their 40's. one daughter was 42 and it was pick up on a routine yearly mammogram. the other dot was age 49 and she found an ab0 normality by self self-breast exam and it was confirmed by a mammogram." now we have a group of unelected people coming forth and saying, you're not supposed to get a ma'am gravment you're not

entitled to a mammogram. and he have we've learned, mr. president, that some insurance companies have already decided to follow that dictate. and this gentleman, a physician, says my two daughters would be dead from breast cancer if that were imposed. i'm fraid that noition these very -- i'm afraid that in addition to these very permanent cuts, this would impose the very type of requirement that we're fearful might come forward on mammograms. mr. crapo: the senator is correct. i'll conclude with this: i think we've all seen that folks are almost falling over themselves backing away from the news on the mammograms that came out just now, but it is a very clear example of the way in which a study can come out from a government source -- or otherwise -- to say that, well, we don't really need to have this kind of health care in the united states, and it's a cost saving and what do you think is the potential for this

commission to say, well, you know, we are charged with saving quofts in these programs, and we are -- costs in these programs, and we're going to do that. i would suspect that the mammogram issue is not a place where they would do it. but sometime this commission is going to save tens of billions of dollars in addition to these cuts by reducing services. and try to color it the way you want, you cannot make this kind of reduction in health care service, personnel and infrastructure without redos ducing the access and -- without reducing the access and quality of care. these issues face every state in america. and we are going to see in this arena a dramatic reduction of the quality and content and quantity of health care that our medicare beneficiaries today see because of these proposals and they are being done not in order to make the medicare system more solvent but to finance yet

another major federal entitlement program that will cost hundreds of billions of dollars. as a matter of fact, if you look at the true numbers, the cost will be over $2 trillion in a full ten-year period of time. and so there's a lot more that we could say, but i know that my colleagues from mississippi and florida have some remarks that they would like to makers and so -- that they would like to make, and so i will yield to them at this time. mr. lemieux: i want to thank the gentleman from idaho for his great remarks today. and i want to follow up on what he started to discuss and continue also with the comments from my colleague from arizona about medicare advantage, because it seems to me, being a senator from florida, where we have the second-highest senior population in the country, the highest per capita senior population, we have 3 million people on medicare, more than 900,000 on medicare advantage, that florida is going to receive the worst impact perhaps of any state in the country because of this proposal. so i'm here today to talk about

this, not just as an american but as a floridian because i want my fellow floridians to know, especially seniors, of what's in this bill and what it means for them. that's our job. it's our responsibility to read through this document, this 2,074-page bill that we just received a day and a half ago and to talk about what it means for the average american ands -- in my cairks the average floridian. so we come to find out today that this medicare advantage program that 900,000-plus floridians enjoy, that we're going to have a substantial cut it the benefits. and this is not just fringe benefits. these are things that people need to stay healthy -- eye doctors, hearing aids, programs to make sure that folks stay in shape, all sorts of things that contribute to the health and wellness of seniors. and our seniors enjoy this program. the popularity of this program is sky high.

but we're finding out today -- and i'm looking at this map. florida geght the worst impact s getting the worst impact of any state in the union. only louisiana is getting the same impact. 81% of reduction in the benefits to our seniors. it means they are not going to have the health care that they enjoy now, which is what the president promised. right now this bill says that the benefits offered will drop from $135 a month to $42 a month. florida seniors will lose 81% of this additional coverage. i had some constituents who've written in to me because they've been hearing about these problems, mr. president, and i want to read one of these or two of these letters to you from floridians who are concerned about losing medicare advantage. this one is from dennis shelton in plante city, florida, which

is in central florida. he writes to me, "senator lemieux, i am writing to express my deep concern about the proposed cuts in medicare advantage funding. i am currently enrollerolled inn advantage program that are criewrm for me to get medical attention. the plan provides doctors, medicines, urgent care and my diabetic supplies. the plan does this significantly better than traditional medicare at a reduced cost. my regular visits, i have been able to maintain reasonable health. if the cuts reduce services, then my health will suffer along with other seniors that are in the advantage program. this is distressing and i sincerely hope that you will strongly advise fellow congressmen how important medicare advantage programs are to seniors all across the united states." so, mr. president, i'm new to this body. i've only had the honor of serving here for a couple months. so i'm still learning the ways of washington. but my understanding of this health care process and this

health care bill was we were going to maintain quality, we were going to try to cut costs for people who've experienced the high cost of insurance, and we were going to try to provide more access. but what i'm finding out from this proposal is that we are going to cut quality for seniors. and we're not going to reduce the costs of health care for the 170 million people who actually have insurance. so it occurs to me that the goals that we ar were set out at being achieved by this plan. and we're still -- we're taking a program that seniors rely upon and that seniors paid into their whole life through their wages and we're going to cut a half of a trillion dollars out of it, a program this in seven or eight years is going to run a deficit and be in tremendous trouble. so the question i have -- and maybe my colleague from mississippi can help me with this since i'm new new to the chamber -- is why are we going down this path?

this doesn't seem good for seniors. it doesn't seem good for people. in any walk of life in america, especially in light of what my colleague from mississippi pointed out with the mammogram issue that came out and the self-breast exam issue that came out this week. why are we going down this path? a senator: well, i appreciate the gentleman asking that question, and the answer is there's really no reason for us to go down that path. early in our hour, the republican whip pointed out that there are many proposals the republicans have that do not require the huge expenditure, the huge expansion of federal power and actually are relatively simple and relatively inexpensive. for example, we have a proposal by senator ensign to reduce junk lawsuits against doctors. the medical care access protection act, only 28 pages

compared to these huge pieces of legislation in front of us. that wouldn't cost anything. it certainly would not require any reduction in medicare to combat waste, fraud and abuse by my friend from florida, and i congratulate him for that. mr. wicker: only 21 pages, something republicans have been begging for and arguing for for years and have been stymied on, allow small businesses to pool resources to purchase health insurance for employees. small business people in restaurants and realty companies, small motels ought to be able to pool together and have the same purchasing power that -- that the huge corporations have. but that -- that would only take 88 pages. it would not involve a cost to the federal government and certainly would not involve these draconian cuts of half a

trillion dollars to -- to medicare and medicare advantage. further, we could purchase health insurance across state lines. you know, we certainly agree there's not enough competition in health care purchasing. i would love to see a commercial someday with someone coming in and said, i've got great news; i just saved a ton of money on my health insurance by stwoichg xy -- switching to xyz company. we see that in car insurance. we see that in life insurance. there's vibrant competition. but if we opened up competition across state lines to the 50 states, and if i could buy insurance from idaho, i might find a company that gives me better service, that provides better care or reduced premiums, or if i could look at a florida insurance company or if the gentleman from florida might look at a mississippi company. and we would use good, old

american competition that has worked in our market society for years but has not been allowed to work in the area of health insurance. and then, of course, health savings accounts, a one-page bill by my friend from arizona and our colleague, senator demint. and then wellness and preventi prevention, again, only a simple 14 pages. none of these would require cuts to medicare. none of these would involve th the -- the $2.5 trillion that this spends per decade once it is fully implemented. so the answer to the question of why we're doing it is, it's not necessary. and i guess the reason that -- that people might be doing it is that they -- they just believe that big government works well. now, i have a different view on that. and i see, as the gentleman

pointed out, all of these federal programs that are not exactly working as efficiently as they were projected to be. my dad is on medicare. we're going to protect medicare. republican and democrat, we're going to do that. but as the gentleman pointed out, it goes broke in the year 2017 and we certainly don't need to be taking from medicare to pay for a new entitlement. medicaid, as has been pointed out, many doctors will not take medicaid payments any more because it's broke and it doesn't reimburse at -- at a market rate. and so we see in my home state of mississippi, 60% of the doctors will not take medicaid, and yet there's some people in this building, there's some

people in this country within the sound of my voice who believe that somehow a huge $2.5 trillion takeover of one-sixth of our economy can work and will not be like the census, like freddie and fannie, like the post office and the highway trust fund and will not be broke. it is -- it comes down to a difference in philosophy. but certainly we ought to all agree that savings that we find in medicare ought to be used to shore up medicare and make sure it's there for -- for people like my and -- and -- and people who are going to -- are going to rely on that program for years and years to come. mr. lemieux: well, i thank the senator for that explanation. that's very helpful to me. what really is disconcerting about the path that it seems

that we're on is that we're going to have this governmen government-run health care system, and if already now people can't go see their doctor if they're on medicaid because doctors won't take medicaid, and if it's growing more and more the case that you can't see a doctor if you're on medicare. and i have some information here about 29% of beneficiaries surveyed saying they're having a problem finding a doctor who will take medicare. and there's a gentleman from florida, from sanford, florida, earl bean, who was interviewed this week, and he said, "i call about 15 doctors and was told repeatedly that they were not accepting medicare patients." they wouldn't even take his name when he called up. so what i'm worried about is that we're going to enter into a system where five years from now, ten years from now, when everybody in the country is basically on a government-run health care program, through medicare, medicaid or this new program, which, unfortunately,

we all think will push the private insurers out of the business eventually and we'll all have government health care, is we're going to be going places there will be a hundred people waiting in the room, if we can get at doctor at all. they'll be rationing the care. they won't be providing mammograms like this recommendation came out this week from the government task force for women in their 40's, be discouraging self breast exams for women. and we'll all have very poor-quality health care unless you're wealthy. and what's already happening now is that those folks who are wealthy, there are doctors now who are not taking medicaid, they're not taking medicare and they're not even taking insurance. so what concerns me -- and maybe the gentleman from mississippi could comment on that -- is that if we enter on this path, is we're going to go to a world where the majority, the vast majority of americans are going to have poor-quality

government-run health care and only the very rich will have access to good doctors and all the best quality of health care. and that's -- that just doesn't seem to me like an america we want to live in. mr. wicker: i think this constituent of mine from brandon, mississippi, said it very well in a recent e-mail i received. she says -- obviously she's dependent upon home health care. she says, "i support the goal of health care for all. however, that goal should not come at the expense of frail elderly and disabled home-bound medicare beneficiaries receiving care in their homes and communities." and she points out what this legislation would do to home health care. truly, this bill before us and the one from the house and the one from the two committees takes money from america's seniors to the tune of half a trillion dollars, and instead of

shoring up the system that needs to be enhanced and protected, it puts that money in the new government entitled program -- entitlement program that we have exhibited here. and i certainly believe we can do better. mr. kyl: mr. president? mr. president, i want to interrupt my colleague from mississippi for a moment to ask him, or i think the senator from idaho has some experience with this as well, we've been talking about a half a trillion dollars in cuts to medicare but we haven't even talked about the biggest one yet. we've talked about the cuts to medicare advantage. we've talked about the cuts that will be ordered by this new medicare commission, but i guess i'd ask my colleague from idaho, isn't it true that the biggest dollar cuts to medicare are going to come because we're going to pay the doctors and the hospitals and the nurses a lot less money, and, of course, every one of my stitch twheants have talked to me about this said, wait a minute, if you're going to pay them a lot less

money, i'm having a harder time finding a doctor that will take medicare patients, sthaiptd goin, isn't thatgoing to resulte and in effect rationing of care when there aren't enough doctors and nurses to take care of me any more because they're not being paid enough any more to even keep their doors open? mr. crapo: well, the senator is exactly right. as a matter of fact, if i understand the legislation correctly, it assumes that the current projected cuts for physicians are going to happen. that's how it that says it's not going to increase the deficit. now, you and i both know that this congress will not let that happen. but even today, 29% of medicare beneficiaries looking for a primary care doctor had a problem finding one because there are -- both with regard to medicaid and medicare, because of 9 problems we've been -- because of the problems we've been discussion here, there are fewer and fewer providers who will take patients in those programs. mr. lemieux: mr. president, i

was wondering if i could ask my colleague and leader from arizona a question, because we're about to the end of our time. my understanding, senator, is that we're going to have a vote tomorrow at 8:00, and, again, i'm new here so i was hoping that you could explain this for me. my understanding is that we're going to vote whether or not to proceed on this bill. and it's not going to be this bill, it's going to be some kind of shell bill or something, which hopefully you can clear up for me. but i am told by folks who work with me that the congressional research service has said that when there's a vote to proceed on a bill, that 97% of the time that bill passes. so it seems to me that if we're voting tomorrow to proceed on this, that's really a vote on this bill. do i understand that correctly? mr. kyl: mr. president, i would say to my colleague from florida, that's exactly right. and i was interested in that congressional research service report, a totally nonpartisan report, which essentially makes the point that if you vote to proceed to the bill, 97% of the

time you're voting to approve the bill because they end up passing. so those of our colleagues who say that they have problems with this bill, serious problems with the bill, are enablers. if they vote to proceed to debate this bill, they are enabling those who want to pass a bad bill to do so. because that's exactly what will happen. in order for them to try fix the bill, it would take 60 votes to get an amendment passed. and that's a very tall order around here. and as to the second part of the question, yes -- and this may be a little confusing to folks -- but what the majority leader has asked is that we vote on a cloture petition to proceed to a house bill that has to do with bonuses for a.i.g. people. now, the ordinary -- and you say, what does that have to do with this? the answer is, it has nothing to do with this. but the leader ordinarily would have taken the house bill, which is the bottom half of this stack here, and he would have taken the house-passed health care bill and asked to proceed to

that bill. if we then agree to proceed to that health care bill, we would -- he would then substitute his own version, which is the second half of this stack here, and then you'd have a senate version that we would begin to amend or act on, or at least debate. i don't think the majority leader wanted those on his side of the aisle to have to vote on that house-passed health care bill. it doesn't appear to be very popular out in america. in fact, by about 2-1, the american people say they don't want to have anything to do with that bill. so instead, we're going to a shell bill that has nothing to do with health care and then the leader will simply shift to his substitute health care bill, and as my colleague from florida notes, once you vote to begin the debate on this bill, you have put in motion the process by which it could and in 97% of the cases does end up getting

passed into law. so for those colleagues who say, well, i'm not sure i like this bill but, you know, i'll move the process alone by at least going to it, the time stop it and to say, let's fix before, is the time we're now, not after you get on the bill and it's too late. as my colleague said. mr. wicker: will the gentleman yield? and this reid substitute that will be substituted for the shell bill contains taxpayer funding of abortions and it contains a government-run company to compete with the private sector. and so senators who vote to proceed on this bill in my opinion are playing with fire and -- and very much risking that that type of legislation might come out of the closed room that will be the house-senate conference. mr. kyl: mr. president, the point is this -- unless they've got a way to get 60 votes to get those provisions out, they're, in effect, endorsing them by voting to proceed to the bill because they can't get them out.

so my colleague is exactly correct. mr. wicker: and the best way to get rid of though provisions -- the presiding officer: the time for the republicans has expired. a senator: mr. president? the presiding officer: the senator from florida. mr. nelson: mr. president, i rise to support the majority leader in his motion for cloture to cut off debate to allow us to vote on the motion to proceed which will allow us then to get the bill to the floor in order so that we can debate and start amending this bill. and, mr. president, i want to use the next several minutes to lay out a comprehensive reason of why this senator supports

moving to take up this legislation. i look forward to the mandatory process that will be vigorously attempted to be amended. particularly by the amendment that -- that i had offered a number -- i had offered a number of amendments in the senate finance committee. most of those amendments were, in fact, adopted. there was one in particular that was not adopted on a vote of 13-3. it would save the american taxpayers $109 billion by having the price of drugs that are sold to medicare recipients under medicare part-d that also are eligible for medicaid, but get their drugs under medicare. it would cause those drugs to be

sold at the same discounts that they get the drugs under medicaid. and there have been discounts for a couple of decades because of the bulk purchases of millions and millions -- it's close to 50 million people that get drugs under medicaid. well, there are about 43 million people that get their drugs under medicare. let me correct that. there are 43 million people on medicare. there are some number less than that that are now getting their drugs under medicare part-d. but, in fact, they don't get the same discounts that those very same people in medicaid would get even though they're eligible for those discounts. those people are called dual

eligibles because they're eligible because they're poor to get it under medicaid, but they're also over 65. and, therefore, dual-eligible, they ought to be able to get the cheaper drugs. no, we can't do that. because in the medicare prescription drug benefit that was passed six years ago, those kind of discounts were not allowed. and that is a huge additional cost to the taxpayers of america. the overall amount of medicare drugs being sold, if you got those discounts, would be something in excess of saving the american taxpaye taxpayer $200 billion to $250 billion. for those that are dual

eligible, they call pie for medicaid, but -- they qualify for medicaid, but they get their drugs under medicare, those people, the savings would b be $109 billion. so this senator is going to offer that amendment. it's a high threshold of 60 votes that we have to get on this floor. but, indeed, we will see. and on down the line. now, why am i insisting on continuing to offer this? well, it's very interesting that just recently an aarp study has come out, along with another study called i.m.s., and they have noted that the cost of drugs -- of brand named drugs, their wholesale prices have

increased in the year 200 20089. contrast to the rate of inflation, which was about zero percent. so you see the cost of drugs are continuing to go up, it's time to give our people some relief. and it's with that $109 billion extra, you could do a lot with it. first of all, you could lower the deficit by $109 billion so that whereas this bill brought forth by the senate majority leader saves the treasury money over the 10-year period, reduces the deficit by $130 billion. you could add anothe another $100 billion to that. we could be lowering the defic

deficit $230 billion. but you could take part of that money that you would save the taxpayers and you could use that to fill the doughnut hole. the doughnut hole is the strange creature in statute that gives senior citizens under medicare some reasonable compensation for their drugs up to a certain level and that level is generally between about $2,500 and $4,500 of total drug purchases within a year. but once they get into that zone, that doughnut hole, in fact, they get no assistance from medicare. that's called the doughnut hole. well, that's something else. you can help senior citizens fill that doughnut hole so that they're not bearing the full cost of those drugs when they

get hit with huge drug expenses in a particular year. and so we will see what the will of the senate is as we come out here and start to vote. mr. president, the reason that it's important tomorrow night at 8:00 for us to get 60 votes to shut off debate so that we can go to the motion to proceed to get this bill to this floor, the reason is that we need a debate. we can't afford not to have a debate. and in what is known as the world's most deliberative body, that's what we do, debate and

amend and try to perfect. now, is anyone denying that health care, the cost of health care, the availablity of health care, the availablity of health insurance, the availablity of health insurance at a reasonable price, is anybody disagreeing that that's not a problem in america? our people are hurting. and so one of the main purposes of bringing this legislation out here and trying to find a reasonable solution is to make health insurance and health care available and affordable. for example, what about if you have a preexisting condition? you can't get health insurance. we're going to change that in this legislation.

or what about if you're sick and your insurance company suddenly comes and says, we're going to take away your insurance? we're going to cancel your health insurance. is that a good outcome? there's nobody in america that thinks that's a good outcome and that's what we're trying to change. and, by the way, that's what the bill proposed by the majority leader will, in fact, do. and what about all of those 46 million people out there that don't have health insurance? well, first of all, a lot of those folks do get health care, but where do they get it? they get it at the most expensive place at the most expensive time. they go to the emergency room

after what could have been very possibly prevented becomes an emergency and so it's at the most expensive place at the most expensive time. and, by the way, guess who pace? do you think that all of those costs suddenly evaporate in the ether? no, they are born costs born in a hospital ultimately born by all the people who support the health insurance system. that is those who have health insurance policies and pay premiums. and it's no small amount that we pay. as a matter of fact, nationwide the additional cost to a family health insurance policy to take care of the uninsured people is

between $900 and $1,000 per year extra. it's a hidden tax on all the rest of the people that are paying their health insurance premiums. in my state of florida, it's even higher. it's estimated to be $1,400 per family policy per year. a hidden tax. and that is a hidden tax that will disappear if you can bring in those 46 million people nationally who are uninsured, four million of them of which are in florida, if you can bring them into the system. now, will we bring them into the system? the bill that the majority leader's put on the table will cover 98% of all americans.

-- americans with health insurance. 98%. and that's the entire spectrum of americans that receive health care. is that worthwhile doing? well, i certainly think it is. now, i said at outset that this bill also tries to approach this in a responsible financial way. the actual cost to the bill are about $848 billion over 10 years. but that $848 billion is more than paid for because at the end of that 10 years there's an

additional $130 billion that's leftover. that's surplus that will go directly to lower the deficit. the projections by the congressional budget office for the second 10-year period is at least a $650 billion reduction of the budget deficit in that 10-year period and possibly as high as $1 trillion in lowering the deficit. and so what does that tell us? well, what it tells us is that one of the reasons that we need a bill coming out here on the moore is -- on the floor is that not only do our individual americans have difficulty paying for the cost of health care, the united states government is having difficulty paying for the

cost explosion of medicare. and unless we start getting those costs under control, then, in fact, we are going to be in an unsustainable proposition with medicare. and so a system of revising health delivery capabilities, so people are not being canceled, no preexisting conditions, people can get health insurance, and it is affordable rates, but at the same time starts lowering the overall cost to not only individuals, but to the u.s. government, it seems like, to me, that that is a desirable thing. so you will hear -- and we just

heard -- comments about how medicare is going to be cut. well, there are clearly efficiencies in medicare that need to be wrung out. let me give you an example. right now, we have what is known as medicare fee for service. it basically pays the doctor's bill that is submitted for the person that is eligible for medicare. well, what happens is that the medicare patient goes to this specialist, that specialist, that specialist, and all of them aren't talking to each other. and this one orders this particular set of tests and that one because he doesn't know what that one's doing is ordering the same test, but medicare is all

getting the same bill. this bill in reforming health care delivery is going to try to get at that. it's going to set up accountable care organizations. it's going to set up electronic records so it's no more of this shifting around and, oh, i didn't get the report. it's federal government to be -- it's going to be there, available immediately. these are obvious technology increases that we have to do. all right. that's medicare fee for service. now, how about a program called medicare advantage? let me tell you what medicare advantage is. medicare advantage is a fancy word for a medicare h.m.o. you know what an h.m.o. is? an h.m.o. is an insurance company. it was originally designed in the late 1990's that you could

deliver health care to senior citizens in medicare through an h.m.o. cheaper, so when it was first set up, medicare h.m.o.'s were given 95% of fee for service because they were going to save costs. they were going to save costs to the individual. they were going to save costs to the government. 95%. but lo and behold, in 2003, in the medicare prescription drug benefit, it not only set up what i described a while ago as this unusual doughnut hole and drugs that can't be discounted to the federal government when it's buying drugs in bulk for millions of medicare recipients, it also set up we're going to give a cushy arrangement to insurance companies that insurance companies that want to

sign up medicare recipients are going to get 14% more per patient, 114% instead of hundred% of -- instead of 100% of medicare fee for service. is there any wonder that costs are exploding in medicare if suddenly a program gets 14% more per patient than what the standard base line ought to be, which is medicare fee for service? it doesn't take a rocket scientist to figure that out. and because insurance companies, medicare h.m.o.'s, its fancy name is medicare advantage, because they get more, 14% more, then they can offer additional things to the senior citizens,

and this has proved to be quite popular. and basically, 30% of all medicare recipients in my state of florida have signed up for medicare advantage, and indeed the biggest thing that they have that is desirable -- you hear about eyeglasses and hearing assistance and so forth, but the biggest thing that is the most popular is that because the insurance company is getting paid so much more per person, it can then use part of that money to pay the co-pays on medicare like medicare hospital insurance part a and part b, as well as part d, the drugs. so it's very popular. so what i said in the finance

committee is obviously we ought to reform the system, and i can tell you this senator didn't vote for it six years ago which set up this system which was a cushy system for insurance companies as well as the drug companies. but the fact is we have it, and so this senator said in the finance committee, all right, what i want to do is i want to grandfather the people that have it in florida in, so that on a going forward basis, when this takes effect -- in this bill it takes effect in 2013 -- that when it takes effect, that it's only those new people signing up that will operate under the new system that will make it more streamlined, but that those who have the existing benefits for

medicare advantage will not be cut. i offered that amendment along with other senators in the senate finance committee, and that amendment was adopted. so the statements that have been made on this floor about florida medicare advantage recipients being cut in florida is not accurate. on this bill. i fought for that. everybody knew i fought for that. and of the 949,000 medicare advantage recipients in florida, at least 800,000 are operative under the formula that we put in and the remaining 149,000

virtually would not be affected anyway. now, i can't speak for the other states, but i can sure speak for florida. that is in this bill. those other senators who offered the amendment with me in the finance committee had things that tended to their states as well that were part of that amendment. but that's what the situation is with regard to this legislation. now, let me say that if we can get this legislation out of the senate and get it to a conference committee with the house, the house has a whole different approach. the house works on streamlining medicare advantage from the basis of not something known as competitive bid, which is in the senate bill, but what is known as fee for service as the target

benchmark. and that does not have the draconian cuts, in my opinion, to many of our medicare advantage recipients. but i want the record clear here that with regard to florida, florida medicare advantage people have been grandfathered in of those who are in existence, and those who still would be in existence having signed up for medicare advantage until the date at which the new system would start. mr. president, -- or madam president. i see we changed, and it's such a pleasure to have the esteemed senator from minnesota in the chair. madam president, there is room

for improvement. we spent two full weeks in the senate finance committee on this legislation in committee amending. we had spent three months prior to that discussing it. you can imagine in a nation as diverse and complicated as ours in a health care industry and a health insurance industry where everybody and his brother and sister have their finger in the pie how complicated this is. but that's the reason for the amendatory process, to improve, to perfect. madam president, i want to wind up my remarks by giving a

picture of the totality. we have had so much of the debate ever since summer dominate on the concept of a public plan. i think now we hear that the public plan by many organizations have come out and said that max it's going to affect four million or six million people. if it affects six million people that sign up to a public plan, if there is one in existence -- and of course the majority leader has in here not mandatory. he has it at the option of a state that they can withdraw from having a public plan. but if the max of six million people signed up on a public plan, that's 2% of the entire country. and yet, you would think that

that was the only thing when you listened to the arguments, and sometimes we watched fights in these town hall meetings back in the summer. you would think that that was the whole thing that this whole health care reform was about. and the max it's going to affect 2%. now, why is that? why is it that it only affects 2%? well, look at the whole population that we want to give health care delivery to. take my state of florida. approximately -- and i'm rounding these numbers -- approximately 50% of our people in florida get their health insurance from their employer and they're in a group policy. another 16% in my state get their health care from medicare

because they're eligible at that age. another 10% in my state get their health care from medicaid because they are either qualified under the income level or they are disabled. now, add that up. that's 76% right there. of all the people of florida. that includes children. okay. now, what about the remaining 24%? about 4% or 5% of our people also have health insurance, but they pay through the nose because they're buying an individual as opposed to a group policy, and if you're buying it individually where all the health risk is on one life, the costs of those premiums are very, very high, and the

remaining 19% are the uninsured. that's the population of my state of florida. now, that will vary with different states. obviously, in florida, we have more aged 65 and therefore eligible for medicare than most states because i have a high percentage of senior citizens. but you can see now what we're going to do is over here for this remaining 24%, we're going to set up a health insurance exchange, it's going to have -- in the case of florida, it's going to have about potentially four million people in it. it's going to be the uninsured that are now going to have the access to health insurance with no preconditions and they can't cancel their policies and it's

affordable and also available to those people who, in fact, have policies that they can't afford, usually the individual policies. there will be some small business employers, for example, 50 employees or less that will not be offering health insurance , that their employees will be for the first time able to go to the health insurance exchange over here and be able to get health insurance. all right. the competition in that health insurance exchange is going to have a public plan if a state approves, and that's why it comes down to such a small percent, and that's why an issue

has dominated the debate but is not the main issue of this issue. the main issue of this issue, this legislation is to provide health insurance and health care to our people that is available and affordable. and i'll close with this, madam president, we've all heard these stories because people have been coming to us in our town hall meetings, on the phone, in the airport, back during the parades, at the meetings, and they have been telling us these very, very tragic stories. the woman who is in the middle of chemotherapy and suddenly gets a cancellation notice from her health insurance company.

the person who desperately needs health insurance and can't get it, and who has had it for some period of time. the person who is hanging on for dear life to that job because that job that they have is not only their means of financial remuneration but is also their ticket to having health insurance. these are the tragic stories that we want to change, that we want to make people's lives better. we've got to start somewhere, and that point of starting is going to be at 8:00 tomorrow night, saturday night, because the senators are going to parade on this floor and indicate yea or nay on whether or not we are going to shut off the filibuster

in order just to get to the motion to proceed which will then allow us to get to the bill after thanksgiving. it is absolutely essential for the sake of our people that we bring this legislation to the floor and that ultimately we get a product that we can pass and get it on into the conference with the house and have an agreement that the president can then sign into law. madam president, i yield the floor. a senator: madam president? the presiding officer: the senator from delaware is recognized. mr. kaufman: i rise this afternoon to talk about the topic that is on the mind of each and every senator today: health care reform. first off, i want to congratulate our majority leader, senator reid. he has accomplished something that has not been done in years. he has the senate on the

precipice of debating a major health care reform bill on the senate floor. i agree with the senator from florida, tomorrow night at 8:00 we should come to the floor and we should move this bill. it is essential that we pass health care reform this year. the present system lets down all americans and we need a new health care reform system, and we should move this bill, and then we can debate, we can amend, as the senator from florida said. we can deal with this bill, but it is essential we move in bill. senator reid melded the work of the finance committee, the health, education, labor, and pensions into one bill that we stand ready to bring to the floor. if people don't acknowledge that accomplishment, they are forgetting history. for all the efforts to reform our health care system back in 1994, the senate never came close to bringing a bill to the floor to debate. because of the searing experience the congress went through back then, it took

another 15 years to pass before congress attempted another major reform of our present dysfunctional health care system. i believe that if we don't get it done this year, it might take another 15 years or more before we will bring it up again. and lord only knows what will happen to the health care system in this country in the interim. but thanks to senator reid and chairmen baucus, dodd and harkin as well as the tremendous efforts of their members and committee staff, all their long hours, weekends in the office, time spent away from their families, we stand here this afternoon literally aday away from the first procedural vote on the patient protection and affordable care act. make no mistake, we cannot afford to wait another day to fix our health care system. we need to pass health care reform because the trajectory of our national health care expenditures is out of control. in 1979 we spent approximately

$220 billion as a nation on health care. $220 billion. by 1992 we spent close to $850 billion. and in 2009, we will spend $2.5 trillion on health care. from $220 billion in 1979 to $2.5 trillion in 2009. the trajectory clearly is absolutely unsustainable. we need to pass health care reform because premium costs for middle-class americans are rising at an astronomical rate. take my home state of delaware, for example. in 2000 the average premium for family health coverage in delaware was just over $7,500. in 2008, that number had jumped to $14,900, almost doubling in just eight years. and if we do nothing and allow the current health care system to continue, the same premium for family coverage is expected to reach $29,000 in 2016,

another doubling of the price. think about it. every eight years our premiums doubling in size. that is simply unaffordable. we need to pass health care reform because failure to do so will drive more and more americans into bankruptcy. today bankruptcies involve medical bills that account for more than 60% of u.s. personal bankruptcies, a rate one and a half times that of just six years ago. and keep in mind -- keep in mind -- 75% of the families entering bankruptcy because of health care costs actually have health insurance. to repeat: more than two-thirds of all bankruptcies due to medical expenses are from americans who have health care insurance. the number is simply appalling. we need to pass health care reform because small business

owners and their employees are desperate for relief from the cost of health insurance. right now small business owners and their employees pay much higher premiums than their counterparts in large corporations. in fact, during the past five years one in five small businesses reported premium increases of 20% annually. add that up and that is 100% over five years. imagine paying 100% increase. largely because of the increase in premium rates, fewer and fewer small businesses offer coverage to their employees. for example, in 2000, 68% of small businesses were able to offer health insurance coverage to their employees. by 2007, just 59% of small businesses offered health benefits. that's a reduction from 68% to 59% in just seven years. small businesses are the engine in our economy and will be the catalyst to get us out of this

recession. it is time to make it easier for small business owners to provide health care insurance for their employees so they can retain workers they have and hire more to help lift us out of this economic distress. we need to pass health care reform because failure to do so could bankrupt the country. just look at medicare and medicaid. one of the biggest driving forces, in fact the biggest driving forces behind our federal deficit is the skyrocketing cost of medicare as well as medicaid. in 1966, medicare and medicaid accounted for only 1% of all government expenditures. they now account for 20%. if we do nothing to start bending the cost curve down for health care costs for medicare and medicaid, we will eventually be spending more on these two programs than all other federal programs combined. i am pleased that the patient protection affordable care act

begins to tackle these problems and begins to reform our health care system. it's past time. this bill is fiscally responsible. anyone concerned about our budget deficits should embrace this bill. according to the congressional budget office, the bill will reduce deficits by an estimated $130 billion over the first ten years, from 2010 to 2019, and by more than .25% of g.d.p. in the decade after. this amounts to about $5 billion in 2020 and several hundred billion dollars over the next nine years. this is not chump change, this is real effective deficit reduction that will help our economy over the next 10 to 20 kwraoefrplts in addition to reducing the deficit, the bill strengthens the medicare program. contrary to the claims of the bill's critics that you hear on the floor, the patient protection and affordable care act has coverage for medicare beneficiaries. it doesn't cut a single service. let me repeat: it doesn't cut a

single service. for instance, the bill provides seniors with free annual wellness visits under medicare, where they can develop personalized prevention plans with their doctors to address their health conditions and other risk factors for disease, making the conditions easier and less costly to treat. the bill also eliminates out-of-pocket costs for recommended preventive care in screenings like mammograms. in terms of prescription drug coverage the bill helps seniors manage the cost of the doughnut hole and kphaeurbd coverage by giving a 50% discount on brand-name drugs to low- and middle-income seniors. most importantly the act helps ensure the sustainability of the medicare program for years to come. in the past year medicare spending has increased by roughly 8% a year. according to the c.b.o., under this bill the annual growth rate for medicare dropped substantially to 6% for the next several decades.

adjusted for inflation, c.b.o. estimates that medicare spending per beneficiary under this bill would increase an annual average rate of growth of roughly 2% during the next two decades, much less than the roughly 4% annual growth rate of the past 20 years. right now the medicare hospital insurance trust fund is projected to become in this bill, the date of ins&l veteran sift trust fund is pushed -- of the insolvency of the trust fund is pushed back four to five years. this bill is good for senior medicare and good for the federal budget. small business owners struggle to provide their employees with affordable health insurance. this bill will help small business in this quest. the bill will provide a sliding scale tax credit based on the number of employees and average annual wages of these employees to help these small employers pay for health insurance for their employees. this tax credit is estimated to reach more than 3.6 million small businesses nationwide.

in addition, small businesses will be able to purchase insurance through the new state-based exchanges. these exchanges would allow small businesses to expand their risk pool and, thereby, lower premiums. the bill is a win for small business. the bill helps protect middle-class americans against the worst abuses of the insurance industry. no longer will americans be denied coverage because of preexisting conditions. let me repeat that. no longer, if we pass this bill, will americans be denied coverage because of preexisting conditions. no longer will insurers be able to rescind your coverage once you get sick and you actually need the insurance that you've been paying premiums on. no longerer will insurers be able to charge people more based on their health status or gender. the bill protects the finances of middle-class americans and helps reduce the number of medical-related bankruptcies by placing a cap on what insurance companies can require families

to pay out of pocket. it also restricts the use of annual limits and prohibits the lifetime limits on insurance benefits, which is especially important for americans with high-cost conditions to treat. and it creates a health insurance exchange that provides a public insurance option to compete with private insurers to provide consumers with more choice. this will make a great difference in states where one or two insurance providers dominate the marketplace and where there is no true competition. these are good, strong provisions that will help provide health security and stability to all americans. the bill is strong in two other areas as well: promoting prevention and wellness and cracking down on waste, fraud, and abuse. on the prevention front, the bill recognizes that we have to move away from a system that encourages people to wait until they really are sick to seek treatment. instead of encourage prevention in early treatment of diseases

which can help lower the cost of treating patients. the bill recognizes the need to shift this emphasis by eliminating any co-payments and deductibles for recommended preventive care and screenings such as cancer screenings, colonoscopies and mammograms. built would allow employers to offer premium discounts and other awards for up to 30% of the total premium for individuals who quit smoking, lose weight, lower their cholesterol or blood pressure or take other steps to improve their health status. we've seen how successful this type of program can work in companies like safeway. all these measures will help increase the use of preventive measures and reduce the need for costlier treatment that results from waiting too long to treat a condition or disease. finally, i want to highlight the measures contained to reduce waste, fraud and abuse that exists in our current system. each year health care fraud drains between $72 billion and $220 billion from doctors,

patients, private insure i.r.s. and state and federal government. left uncheck, fraud drives up the cost of care while reducing public trust in our health care system. i am pleased that this bill will increase the funding for health care fraud and abuse control fund to fight fraud in public programs. in fact, c.b.o. estimates that every $1 invested to fight fraud results in approximately $1.75 in savings. in fact, c.b.o. estimates that every $1 invested to fight fraud results in approximately $1.75 in savings. the bill also establishes new penalties for submitting false in fact and restricting payments for medicare and medicaid and the schip schip. by reducing the amount of fraud, waste, and abuse, toll rating the health care system would be able to bring health care costs down for everyone. madam president, this is a good

bill. i've only touched on part of this bill, as time does not allow me to discuss every single proirks including the fact that the bill will extend coverage -- insurance coverage to an additional 31 million americans. that is good bill. it's fully paid for. it reduces short- and long-term deficits. it strengthens the medicare system. it provides stability and security for the middle class. it provides americans with greater insurance chances. it promotes wellness. it cracks down on waste, fraud, and abuse. i applaud everyone for the hard work that went into drafting this bill. as i have said many times, it is time to gather our collective will and do the right thing during this historic opportunity by passing health care reform. we cannot afford to wait another 15 years. we need to act now. we can do no less. the american people deserve no

less. thank you. and i note the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

the presiding officer: the senator from minnesota. ms. klobuchar: i ask that the quorum call be vitiated. the presiding officer: the quorum call is done. the senator from minnesota is recognized. ms. klobuchar: thank you very much. mr. president, i'm going to focus for the next ten minutes on the issue of cost. i know many people have focused on really important issues like the fact that this bill will finally eliminate the limitations on preexisting conditions so that if your kid gets circumstance you don't have to lose your -- gets sick, you don't have to lose your health care. the fact that people are going to be able to keep their kids onary health care until they're

26. niece are very important parts of this bill. the other thing that's very important for the people of my state and the things i heard about all over the last few months was the issue of costs and more affordable caivment and this is why. at $2.4 trillion per year, health care spending represents close to 17% of the american economy, and it will exceed 20% by the year 2018 if the current trend continues. hospitals and clinics are providing an estimated $56 billion nun compensated care -- in uncompensated care. in fact, peter o orszag wrote a piece for "the washington post" that highlights the fiscal importance of passing health care refume. one of the things he stlaid is "looking forward, if we do nothing to slow the skyrocketing cost of health care, the federal government will eventually be spending more on medicare and medicaid than all other government programs combined." he notes that it's time to move

toward the high-quality, lower-cost health care care system of the future. as you know, mr. president, coming from wisconsin, we know how to deliver high-quality, high-efficient care. dhow it in which is, which they do it in minnesota. they do it in washington state. a number of states have figured out how to do t those are the models we need to see all across the country. we need to make health care affordable for everyone and we need to reduce the waste and fraud that plague the current system in this country. in 2008, employer health insurance premiums increased by 5%, two times the rate of inflation. and the annual premium for an employer health plan covering a family of four averaged nearly $12,000. nrvetion mr. president, i tell -- in fact, mr. president, i tell meme around me that you need to know three numbers -- six, 12, and 24. 10 years ago the average family was paying $6,000 for their premiums, health care premiums. now they're paying $12,000. that's an average. i know a lost small companies in

minnesota that are paying a lot than that. but right now the average nationally $12,000. if we do nothing to bend this cost curveg the average family will be paying on an annual basis $24,000 for their health care 10 years from now. meanwhile, a new study found that small businesses pay up to 18% more to provide health insurance for their employees. we are taking about a backpack company up in two harbors, minnesota. the guy started a small company, now up to 15 employees. he told me for his family of four, he's paying $24,000 in two harbors, minnesota, for his family just to make sure they have health insurance. he said if he knew it would have cost that much way back when he started this company, he might not have started this company. now they're providing high-quality backpacks for our troops. those backpacks would hav woulde

existed if he knew it would have cost that. but he was an entrepreneur and we should reward that entrepreneurship. the american people know that inaction is not an option. if we do not act, costs will continue to skyrocket and 14,000 americans will continue to lose their health insurance every single day. we must keep what works and fix what's broken. now, let kneel you about some good news. it's encouraging news that the billy the senate -- the senate is going to start considering and our vote is tomorrow night will reduce the federal deficit by $127 billion in 10 years, and if you go out 20 years, $650 billion reduction in the deficit. that's good news. we achieve these long-term savings bhaik our health care system more efficient, rewarding quality, improving patient outcomes and reducing administrative spending and waste. most health care, as you know, mr. president, is purchased on a fee-for-service basis. so more defendan tests and more

surgesries. according to researchers at dartmouth medical school, nearly $700 billion per year is wasted on unnecessary or ineffective health care. that's 30% of the total of health care spending. one study showed that if the hospitals of some of these inofficiate areas would follow the protocol that the high yow clinic-- --that the mayo clinic follows, we would save $50 billion in taxpayer money every five years for chronically ill patients. $50 billion every five years. that's just one example for one set of patients. that's what we do in minnesota, and we want that same kind of health care, that same kind of high-quality care. we want the incentives, incentives on the federal level that aren't there now, and that's what we're seeing in this reform package. i'm very pleased that the value index that i proposed that was also cosponsored by senator cantwell of washington and senator gregg of new hampshire

was included in the senate bill. this indexing will help reduce unnecessary procedures because those who produce more volume will need to also improve care or the increased volume will negatively impact their fees. doctors will have a financial incentive to maximize the quality and value of their services instead of the quantity. this is supported by the doctors in my state. linking rewards to the outcomes for the entire payment area creates the incentive for doctors and hospitals to work together to improve quality and efficiency. in too many places, patients struggle against a fragmented delivery system, running all over with their x-rays in the back of their car, seeing different specialists, not having someone in charge, not having the quarterback running the team. ink stettedinstead, having 20 we receivers running this way and that. that's why we need this kind of ingratintegrated care. what you pay for is the result,

the combination of service servt give you good results. that's what bundling is about. another good thing about this bill. hospital readmissions cost $17.4 billion. a study found that medicaid paid an average of $7,200 per readmission that was likely preventable. who wants to go back in the hospital if you don't need to? but one of the problems is, if you don't have those quality indexes in place, my state has one of the lowest hospital readmission rates in the country, but if you don't have that quality index in place, you're rewarding bad practices. we want to reward high-quality. put the patient in the driver seat. that's what we do with these provisions in this bill. i'm encouraged that the senate bill includes a provision that calls for reduced payments if you have preventable readmissions. in this bill we work to -- at places like mayo clinic, a patient's overall care is

managed by a one-stop shopping. to better reward and encourage this collaboration, we encourage the creation of accountable care organizations. that's what i hear from the people of my state and across this country. we want more accountability in this health care system. and you know what else accountability means, mr. president? accountability means better enforcement of medicare fraud. when the dollars are so tight, when people are having so much trouble ad fording their -- affording their health care, why do we want to waste billions of dollars on fraud? think about what that money could be spent for to make it easier for people to go to the hospital. this bill and some eaflts that we're going to be -- and some amendments that we're gobbing proposing will bring us much closer to reducing that fraud to bring that fraud down to hold

that's perpetrators accountable, increase criminal penalties. that's important. making sure we have direct deposit, a tbhail senator snowe and i have so that no one can start making out false checks and trying get the money that way. giving our law enforcement officers more tools to go after medicare fraud. we can save $60 billion. in today's "washington post," peter orszag writes "as we gear the home strerchtion the greater risk we run is not