continue to take a terrible toll on civilians, for hosting the review conference. columbia joined the treaty years ago. i appreciate the fact that the state department sent a team of observers. but i hope they use this opportunity not only to highlight the hundreds of millions of dollars the u.s. provided for humanitarian demining and assistance for mining victims for years but also learn from the delegations the countries that are parties to the treaty have done already what the united states should have done.

already exceeded the expectations of our advocates. the number of casualties has reduced significantly. at the same time, none of the arguments of the naysayers have come to pass. the united states is the most powerful nation on earth. we do not need these indiscriminate weapons any more than our allies who abandoned them. we have not used land mines for years. we should be leading this effort, not sitting on the sideline. it is time for the united states and the obama administration to join the right side of history. madam president, i ask consent that the full statement and other statements be made part of the record. the presiding officer: without objection. mr. leahy: madam president, have the yeas and nays been requested on this nomination? the presiding officer: they have not. mr. leahy: i request the yeas and nays. the presiding officer: is there a sufficient second? there appears to be. the question is on the nomination of jacqueline nguyen to be united states district

judge. the clerk will call the roll. vote:

test test test test test vote: vote:

the presiding officer: are there any senators in the chamber wishing to vote or change their vote? if not, the ayes are 97, the nays are zero. the nomination is confirmed. under the previous order, the motion to reconsider is considered made and laid upon the table. the president will be immediately notified of the senate's action, and the senate will resume legislative session. under the previous order, the senate will stand in recess until 2:15 p.m. it also costs more than $200

billion less than the house bill. we expect debate and votes on amendments throughout the week as health care dominates the floor proceedings this month. follow live senate coverage as members debate health care here on c-span2. this afternoon, a senate hearing on two pending intelligence nominations. phillip goldberg is the nominee for assistant secretary of the state department's bureau of intelligence and research. and karen wagner plans to testify on her nomination as undersecretary for intelligence and analysis at the homeland security department. the senate intelligence committee holds the hearing. it begins live at 2:30 eastern on c-span3. and tonight, president obama heads to west point to deliver his speech on u.s. strategy in afghanistan. that speech will air on one of the three c-span television networks and at cspan.org and you can listen on c-span radio. and we'll take your phone calls after the president's remarks. all live tonight starting at

8:00 p.m. eastern. >> on this vote the yeas are 60, the nays are 39. 3/5 of the senators duly chosen sworn having voted in the affirmative the motion is agreed to. >> with that vote, the senate moves its health care bill to the floor. starting today, and through december, follow the entire debate and how the bill would affect access to medical care, the public option, taxes, abortion and medicare, love here on c-span2. the only network that brings you the senate, gavel to gavel.

>> next a preview of tonight's announcement by president obama regarding troop levels in afghanistan. from this morning's "washington journal." it's an hour. >> host: senior fellow for the center for new american security. also, write as blog for foreign policy called, the best defense at, ricks.foreign policy.come. three things we need from obama on afghanistan. you write, most importantly, is his heart in it? can he bring along a good portion of the american people, especially part of his base or is he going to say we're giving it 12 months and then we're uotta here? what did you mean by this? explain a little more. >> guest: obama is a great speech maker. people expect him to be eloquent. the question will he also

give the sense after this very long internal policy debate that lasted since the summer, does he really think this is something worth doing or is he kind of begrudging about it? is there is any sense he is not into this heart and soul, i think democratic base especially will run away from this. >> host: what words does he need to say tonight to the american people that indicate to you that his heart is in it? >> i think the words he shouldn't use. if he uses the phrase, exit strategy, a friend of mind said, that is sign this is one-term president. if you're so focused on getting out you're not really talking seriously what you're going to do while you're there, people will sense that. it is not just dogs that sense fear. people also sense fear and insecurity. if it is just, look it, we'll mess around here a little bit and then we're leaving i think especially, opponents in afghanistan, not just the taliban but also the corrupt and abusive

members of the afghan government will say, okay, hunker down for 12 months and we can see the americans out of here and have our own way. >> host: why isn't 12 months a long enough time when you're looking at a his strategy? >> guest: it might be. it might be a long enough time to begin turning things around but you're not going to get the job done in 12 months. it takes time to win the trust of people. it takes time to get rid of abuse sieve and corrupt members of the afghan government. i think it will take several years if it is going to work right. >> host: what does he need to ask of the american people? there was a lot of discussion before when we went into iraq, while the united states was in iraq president bush not asking the american people to sacrifice. does the president need to ask the american people to sacrifice and how can they? >> guest: i think it would be a good idea. since 9/11 it's been a good idea to get the american people involved in this sort of thing. especially democrats talking about paying as you go in the war i which i think would have been a good idea.

i think we've gotten ourselves in a pretty bad financial situation putting iraq war on credit card. now chinese government owns enormous amount of american government debt and is going becoming due, i think some of it heavily next year. so i think being american people the cost of the war is an important thing. a lot of american people are involved in this. i have a nephew who is now at marine officer candidate school. graduates in couple weeks and almost certainly will go to afghanistan next year. >> host: "the washington post" editorial on the issue of cost, lead editorial this morning, paying for war how to escalate in afghanistan without adding to the national debt proposes you add 40 cent gas tax increase over next five years to help pay for this escalation in afghanistan. the politics of that? >> guest: i'm not sure how the politics would play out. i try, i try to avoid

discussing domestic politics because whenever i hear political pundits talk about national security they sound so bad i wonder if i sound so stupid. >> host: why do they sound so bad? >> guest: they don't know what they're talking about. talking heads which i'm being one right now on tv, and as a reporter who covers the military and done it for 20 years, see people casually talk about counterinsurgency without having seen it on the ground it actually makes me think of what it would be look like to write about a political campaign without having seen people campaign and talking to voters. i try to avoid the domestic politics thing. that said i think it would have been a good idea after 9/11, to say, hey, this whole thing, involves partly, our being involved in the middle east for oil. and, thomas freidman, actually has talked about this eloquently in his columns in "the new york times." we should have started an alternative energy policy back then. to try to wean this country from its addiction to middle

eastern oil and eight years later we vent done that in very long term that would be a very good idea. >> host: before we get to phone calls here for tom ricks i want to show our viewers you said there were three things president obama needs to address tonight. one of the other three is, how does what we are doing relate to the security problems in pakistan, to me, a far bigger worry than anything happening in afghanistan? why is it a bigger worry for you? >> guest: look, i love afghanistan. i lived there as a kid. i'm wearing my afghan time. these are national colors of the afghan flag. in terms of national interest there is only one reason we really care about afghanistan and that is because of pakistan. we could actually live with a taliban-held afghanistan as long as al qaeda wasn't there and that is a problem. what we can not live with is the security situation in pakistan deteriorating rapidly. it has been deteriorating. so that you see a possible breakup of that country. it is a very big country.

pakistan has a bigger population than russia. like russia it also has nuclear weapons. it also has a lot of islamic extremists. what you don't want islamic extremists coming together of with nuclear weapons that is one of the dreams in of al qaeda. that is possibility in pakistan. as long as began glan is in turmoil that will spill over to pakistan. >> host: what do you want the president to say about pakistan? >> guest: i don't know. that is heart of the whole problem. what he has to do is somehow get pakistan more serious about countering terrorism inside its own borders and truth be told, part of the pakistani government to this day still supports the taliban. the isi, their internal intelligence organization, is really playing a double game here that we've never been able to stop. and, if anybody can do it i think obama probably has a good chance of intervening but it's a tough act to do. >> host: tom ricks is with

us this morning until the end of today's "washington journal", around 45 more minutes. phoenix, arizona, linda on the democrats line. your first phone call. >> caller: yes. good morning. i hope you hear me. i'm always very nervous. i think what applies about jobs in the united states could also apply in afghanistan. my idea is 100% employing own companies we put 200 people together. either get microloans for 5,000, or they have money of their own which would be paid back through payroll deductions. now, in afghanistan we have to build the infrastructure. we don't need anymore no-bid loans or no-bid contracts, but we need to put the people to work there just like we do here so people can join forces. in america we would go and retool some of these manufacturing buildings, solar and turbines and stop

the president signing stimulus plan and -- in colorado. 100% owned. they build them and install them. >> host: linda, we'll leave it there and focus on your comments about jobs in afghanistan. >> guest: it actually is a very interesting question and i think, linda in tucson has a point. microloans can make a huge difference, especially in third world countries. i have seen this personally in haiti where there was a situation at which women would walk about seven miles every day, buy bread for a dollar, and then come back and sell the bread for a total of a $1.50, for $2 but 50% of their profit, the $1 profit was in interest and they had to pay interest every day. all you have to do is loan each of these women $2 for one year, at no-interest loan, at end of year goes back to $2. and they double their income every day. so microloans in the third

world can make a huge difference. i would be real supporter of that. as i said i lived in afghanistan. you can really change the nature of people's lives with small, simple projects. paving a road, building a bridge, building a schoolhouse. paying for one teacher for one year. having a non-corrupt police officer. these are make huge differences in quality of people's lives. >> host: is the president expected to address any issues like in this evening? >> guest: i think he will speak to it a degree say this is not just a military operation. in fact the military operation is just a preamble to what you really want to do. in many ways our biggest enemy is the afghan government, not taliban. it is corruption and abuses of afghan officials, especially afghan police. if you can get better government, that is very much a civilian effort, then you can really change the nature of afghanistan and you can stop having the afghan government drive people into the arms of the taliban. >> host: that is the third thing that you said we need

to hear from president obama tonight. what are we going to do about corruption of the afghan government, arguably a more troublesome foe than the taliban. why is it more troublesome? >> guest: because the taliban, is really a consequence of the afghan government. if the afghan government based itself, if people trusted it to do what it is supposed to do than the taliban would really evaporate as a problem. you still have islamic extremists. you still have some taliban activity down in the southwest, in the province which is sort of the arkansas of afghanistan but would be irrelevant to daily lives of most afghans. that is the ideal out come. >> host: wisconsin, on the independent line. good morning. >> caller: good morning, greta. i was just wondering with the afghanistan being such a big problem and the reason why we're over there, is, to protect the united states, i was just wondering we've got the airspace pretty

well-taken care of at the airports but how come we don't have a better check on the, on the canadian border and shores and, southern borders? i don't quite understand? when i leave my house, i lock the front door, not, and not leave the back door open. so i don't know if you can answer that or not but just seems very strange to me if you're over there, primarily trying to straighten out afghanistan, and trying to protect the united states people, why, why aren't we protecting the borders? >> host: tom ricks? >> guest: it actually brings home the difficulty of the task we're asking the afghan and pakistan governments to do. the afghan-pakistan border is a mountainous area which there are a lot of al qaeda, taliban extremists and others working both in afghanistan and pakistan.

when we asked them to get that area straight and be humble and keep in mind the difficulty we have actually policing our own borders. i've been down in el paso and watched people simply walk across the rio grande river on monday morning commute care iing are their lunches. they cross illegally occasionally but expect to do so every monday morning. it is a difficult thing. that said we don't see terrorists coming across the border. we don't see suicide bombers coming across the border and detonating bombs in our capital and major cities. so i think it is a similar problem but qualitativelily a much different problem. >> host: a response to your blog what you talked about, three things we need from obama and afghanistan. one of your readers noted they would like to hear from david petraeus on this issue. why is that? >> guest: it is quite striking. i admire him quite a lot as a general and i think he had a terrific affect on the u.s. army's approach in war in iraq.

really intellectual work in understanding it and then also, as a commander and forcing down a new idea of counterinsurgency down through the ranks. that said, it struck me that petraeus was very, very active in selling this new policy in the spring of 2007. president bush leaned on him a lot. i'm writing a article in the post about how general petraeus had been mentioned by president bush at least once a week for something like 3 of running weeks, total of 53 times. petraeus was very visible at that point. petraeus to my mind has been almost invisible on iraq and afghanistan for the last few months. that may be a thing and maybe hey, the president doesn't need me to be out in front. but, i do have the sense that if petraeus was so active on the iraq policy in '07 with president bush, after tonight, after the president's speech, i would

expect him as a good officer to do the same thing for president obama in the coming weeks. >> host: why do you think he has been, as you say, invisible? >> guest: i think he thought it was probably time to keep his head down. not to make trouble for the president. not to be talking about him, making headlines about afghanistan policy. reminding people that president obama still hadn't come to a decision. that it will would be, discretion was better act for him until this point. the question is, okay, now the president has made up his mind. what are you going to do now? >> host: next phone call, bradenton, florida, on the republican line. go ahead. excuse me, democrats line. >> caller: democrat. good morning. >> guest: good morning. >> caller: i was wondering, of course we have to listen to the tonight to see what he exactly has in mind. as we are known, really tremendous problem within pakistan.

pakistan has been developing these al qaeda and taliban for past several years or so. in the past, india lost 65,000 people in kashmir. taliban has recruited 65,000 people plus in kashmir. in the end we are fighting india war. we have fighting with india. why are we doing that? why are we not asking india to take part right now, because if we withdraw, that will be terrible problem for india -- with any problems in the united states. but almost like we are trying to fight an india war. why are we doing that without asking for direct help from india? of course we don't have to -- pakistan with indian troops which it can help with

100,000 troops under our command. >> host: tom ricks. >> guest: this is one thing i like going on c-span you really get thoughtful you really do get thoughtful and informed questions. the caller as to the heart of a problem in many ways. the biggest threat it faces is not terrorism but india. and in fact there is evidence that some of the billions dollars aid we've given them since 9/11 has gone to improving pakistan's nuclear arsenal. it is a terrible thing. you really don't want pakistan to be spending aid money we give it to build nuclear weapons. what we need to get is pakistan going away from india and giving aid with internal stability problem, corruption and the taliban. india can play a big role in that reassuring pakistan that it is not a.

if you want to solve afghanistan you walk the cat back several steps. kashmir is an important thing. so i think india does have a huge roll to play here. in india, the caller is right. has a much more direct interest. if pakistan breaks up. never been a really coherent country but is becoming a less coherent country now. the northwest front tear has always been kind of an outlyer. baluchstan is having more turmoil. punjab, one of the core provinces is looking tumultuous, unstable. yes a pakistan that breaks up and had nuclear weapons loose and islamic extremists would be a problem for us but would be a real problem, immediate problem for pakistan, for india. i don't think india would stand by and let that happen, let loose nukes float

around. i think they would intervene and then you would have a war and civil war probably in pakistan. if you want to solve afghanistan you need to solve pakistan. if you want to solve pakistan you need to get somehow peace between pakistan and india. >> host: is there discussion within the obama administration getting india to have more of a public role in the pakistan-afghanistan equation? >> guest: when richard holbrooke came in as the special envoy to deal with all this, india, was insulted that somehow kashmir was being thrown into this basket and made it very clear they were unhappy with that idea and that holbrooke would not be the american envoy to deal with all these problems especially kashmir. but i do think there is an understanding in the u.s. government that these are related problems, and you need to deal with the whole of them, not just pieces of them. afghanistan in some ways is not just the smallest of these problems but it is the easiest of them. >> host: next phone call,

farmington, new jersey. karen joins us on the independent line. >> caller: yes, hi. i have a very simple point. i oppose the war in afghanistan and i also oppose the war in iraq and i was proven right. those who opposed war in iraq were proven so dramatically right. i'd like to ask mr. ricks, doesn't see that obama will never be able to convince us that we should now support the war in afghanistan because our simple, common sense was proven so right over all the pundits and generals we saw on tv and the congressman who have thrown a trillion dollars at the war in iraq, which we could use in this country so much better? we're never, never support escalating wars or we want to get out of there. thank you. >> host: mr. ricks?. >> guest: you don't need to preach to me about iraq. i wrote a book called, "fiasco" about the war in

iraq. it states and i still believe that the war in iraq was the biggest mistake in the history of american foreign policy. and, even now, we only have a dim sense of its ultimate cost to this country in blood, treasure, credibility and influence. i don't think the war in iraq is over. and, i think we, may only be halfway through watching this play out. i think actually next year in iraq is going to be a very worrisome year. >> host: explain that real quickly. >> guest: in iraq next year you're bringing down american troops very quickly. you're trying to hold national elections, and you have iraqis posturing themselves for a post-american future. all the ingredients for civil war in iraq that were there before the surge, which the surge interrupted, are still there. so the only thing in the equation that is changing the american ability to stop civil war is declining. so i actually think next year in iraq, 2010, will be

like 2003, and 2007, a real turning point year. >> host: what are the parallels then to afghanistan, given what you just said about iraq? >> guest: i don't see a lot of parallels to afghanistan. i think afghanistan is a very different country, a very different strategic problem. i actually thought invading afghanistan was right thing to do after 9/11. when you have an attack on your country, supported by this government in afghanistan, enabled by it, you needed to respond. i actually am more optimistic in the long run about afghanistan than i am about iraq, for two reasons. first, iraq doesn't strike me as having a coherent national identity. it is still very much, it is parts, kurds, shiites, sunnis. second, and afghans do i think still have a national identity despite their years of warfare there. the second and more important reason, afghanistan has experienced islamic extremism. they have had an islamic

extremist government, the taliban, in kabul. the vast majority of afghans didn't like it. now they don't like the corruption and abuses of the kabul government either. and, if you force them to make a choice, they might pick the taliban. there is a good interview i think in "stars and stripes", the u.s. military newspaper with an after began -- afghan villager, look we didn't like the taliban but at least they don't rape your little boys like the police do. that is chilling thought. they didn't didn't like the taliban but they preferred them to having police come in and rob them and rape them. >> host: next phone call, grand rapids, minnesota, robert on the democrats line. >> caller: yes, good morning, mr. ricks. a real honor to speak to you. i read a couple of your works. one quick question, did you write a book about the history of the united states, overthrow and interventions dating back to 1894 with the

loafer throw of hawaii? and, secondly, i think it is rather arrogant and naive of the united states, especially the civilian leaders to think that we can go into afghanistan, stablize that country, and maintain stability when it is untenable. soon as we leave, it will seek its equalibrium. whoever is in charge will resort to the brutal methods that have kept people in power and control there for, for centuries on end, and, initially, going in, invading afghanistan, i believe was tragic mistake. if we would have kept, if we would have kept the aspects of the police force, a strike force, targeting just those people. but as soon as we put boots on the ground there, just like in iraq the gig was up. we kicked a hornets

necessary. we're going to suffer the consequences for those actions for decades to come. >> host: mr. ricks. >> guest: i agree with you. in the u.s. military, through military action can not make afghanistan a stable country. what the u.s. military can do, i think what the president will say tonight, is it can create conditions which afghans can begin to do that. what you try to do is hold back the taliban, contain them, and also, have american troops adjacent to soldiers, in the hope that -- and i have seen this. daud in iraq -- that when you have more american troops -- and i have seen this in iraq -- that when you have more american troops, it improves the behavior of afghan officials. for example, i am told that there are five checkpoint between dnr and the south -- between cancer heart and the south. in those checkpoints, truck drivers are shaken donndown.

you could have american troops side-by-side with the afghan officials and they will stop shaking down every truck that comes through. because that is a tax onhe >> >> guest: if a truck driver carrying a truckload of rice has to pay 50 cents five times, that will be paid by afghans who might only make a dollar every coup couple of days. so you improve the behavior of the afghan government and deter the taliban, stop this vicious cycle that drives afghan people into the arms of the taliban. that doesn't end the problem, you're right. what it does is say, okay, now the afghans have a chance to stand up a police force, stand up an army. i've lived in afghanistan, it's not always been a brutal, violent, repress i have government. when i lived there, afghanistan was kind of a peaceful, tolerant

country. afghanistan sat out world war i and world war ii and actually until the soviet invasion had a rather peaceful 20th century. >> host: the blog is called the best defense, and you can call it at ricks.foreign policy.com. mary in ohio, go ahead. >> caller: hi, mr. ricks, i want to touch on something you mentioned about the pakistan border. yeah, i think obama would have to pull the troops off the indian/pakistan border to get serious about going after al-qaeda, but who has taken up residence on the afghan border? i really don't believe how much money we promise them that they're willing to do that because, like you said, they are more afraid of india than, you know, the afghan border. and you say then it's okay to leave the taliban to run parts of afghanistan?

i mean, personally, i mean, if you think it's okay for taliban to run parts of a country that the way they treat the women, i mean, they kill women for showing an ankle, and they beat 'em constantly. i personally just can't put up with a, their murderous thugs. i mean, you're rg to -- willing to leave them in part of a country where women are treated like they are? i'll take your answer off the air, thank you. >> guest: i agree with your characterization of the taliban, they are murderous thugs. in fact, i recommend to everybody a terrific movie about the taliban era in afghanistan, it's about a little girl living under the taliban. a terrific movie and really heart wrenching. by the way, the other one i mentioned is afghan star, a documentary about post-taliban afghanistan and the guy putting together the afghan version of

"american idol," and it brings home a good sense of the diversity and vivaciousness of afghan culture. it's really a wonderful film. the afghans, by the way, reminded my father who grew up in rural wyoming of the people he grew up with. kind of clint eastwood with a turban on, if you will. very different than other parts of asian. i think you may say we're not going to change the culture of afghanistan, and if the local people say, we want the taliban, fine, you can have them. i think eventually they'll just fall away, but you don't want the perfect to be the enemy of the good. if the taliban is willing to come in to parts of the afghan government and stop fighting, yeah, that's a compromise. is it great, no, but if it ends the fighting, that's a good thing. >> host: why did you live in afghanistan at as a child? >> guest: my father having grown up outside jackson hole, wyoming, wound up the son of a

horse trainer and a ditch digger wound up teaching at harvard as a psychologist, quite an american adventure. and the 1960s my father got sick of all the student riots, he was teaching at columbia university, and said i want to go overseas. they had an overseas professor program, so off we went to afghanistan. i was a teenager. i just loved the country. i knocked all around it. my parents were kind of irresponsible. they had six kids, they were outnumbered. i knocked all around afghanistan by bus, visited, went down to pakistan by bus because the nearest english-language bookstore was in pakistan, and i was 14 years old and i'd say, hey, give me $100, i'm going to go to pakistan for the weekend and buy some books. okay, off i went. >> host: have you been there since then? >> i went back in 2002 and again in 2004 just on a quick visit. i love the country. i would go there on vacation if my wife would go. i used to go skiing in afghanistan. i was a member of the afghan ski

patrol junior grade. it's a really beautiful country. take colorado and give it mountains twice as big. that's the essence of afghanistan. kabul has a climate very similar to santa fe, kandahar more like, say, albuquerque. but a high-drive really great country to knock around, and just rich with history. you'll go around a corner and there's old buddhist monuments or there's greek -- up in the north where the air strike was recently that killed a bunch of people was the oldest greek city-state ever found, a colony of ancient greece built in what is now northern afghanistan. >> host: fayetteville, north carolina, steve. good morning. >> caller: yeah, good morning. my question is kind of about the culture of by sirh stand. are those people, are they kind of committed to that global jihad, or -- which would kind of

always make al-qaeda welcome there, or is there a sense that they could come to resent foreign fighters kind of picking a fight with us and then bringing us up into their mountains? >> guest: well, that's always your hope. i mean, our trump card with al-qaeda has not been anything we've done, it's that eventually they step on people's toes. that's the story of what happened in western iraq in anbar province which was a naturally receptive area to al-qaeda is they eventually cranked off the locals who got mad at them other issues of marriage. the problem in waziristan is they've been there long enough that they've become part of the local life, the local culture. at this point after 25 years, are members of al-qaeda seen as outsiders in waziristan? they apparently are not. they're seen as part of the local scene. waziristan, i think, generally as a culture just wants its

autonomy. i would not think of them as a bunch of islamist extremistjihadis, i think of them more like the apaches, a fiercely independent tribe. that's the question, how do you deal with them without making them feel they're stepping concern you're stepping on their toes? >> host: texas, democrats' line. good morning. >> caller: good morning. my question is to him is, how does the opium trade affect the country, and why isn't it talked about more? >> guest: it is talked about, but usually in despairing terms because there are no good answers to it. we, actually, as americans with our government have played a role in creating that trade not just as consumers of heroin, but in actually creating the fields where the opium is grown. the hell mundt river is one of the great opium-growing areas in the southwest.

in the 1950s america, out of the goodness of its heart, built two big dams on the hell mundt river that prevented it from simply having a spring rush that goes out in the desert and evaporates. now that water's held in dams and reservoirs, they're able to irrigate the opium fields. it's a huge problem in afghanistan. one of the leading experts on counterinsurgency says that the taliban derives a lot of its operating money from the opium trade. the problem is also afghan officials and the government derive a lot of their cash from the opium trade. each of them is getting billions of dollars from it. you can't just simply go and eradicate those fields and, like, burn them. what you'll do is drive more and more afghans toward the taliban. somehow you have to interrupt that trade and not alienate the people. it's doable. this was done in turkey, as i understand it, in the the

1950s where the government came in under international pressure and regulated the trade, and the opium crop was bought up and used for non-evil means to provide cheap morphine, painkillers, to third world hospitals around the world. >> host: the president speaks tonight from west point, new york, on his strategy going forward in afghanistan. we'll have live coverage on c-span2 starting at 8 p.m. eastern time, you can also go to the internet, c-span.org, and our radio station to listen in to the president's speech. and after that later this week there will be several hearings up on capitol hill about his strategy. on wednesday secretary of state hillary clinton, defense secretary gates and joint chief of staff chairman mike mullen will be on the hill to testify before the armed services committee in the morning. secretary gates and chairman mullen will return to the hill on thursday to testify before the senate foreign relations committee and the house armed services committee. tom ricks, what will you be

listening for out of those hearings? >> guest: i'll be -- if i were covering them as a reporter, and i've done this sort of thing a lot in the past, at that point you're listening as much to what the members of congress are saying as to what the witnesses are saying. the witnesses will basically be following what the president says in his speech and maybe elaborating on it a little bit. but what i really want to hear is what the congressional democrats have to say. are they simply going to say, president obama, sorry, we're not going along with you, or are they going to say, okay, we're going to give you 12 months and then we're out of here, which is another problem, or are they going to say tell us how this works and at least give the notion a chance. i think the president has a real problem with his own party here, and it's going to be very interesting to watch this week. >> host: go to our web site, c-span.org, for our schedule in covering these hearings. columbia, tennessee, will on the

republican line, you're next. >> caller: yes, good morning, c-span, and good morning to you, greta, and i appreciate what c-span does for the, the american citizen, provides an open window for all three branches of our government. now, to mr. ricks, i'm wanting to ask him something related to -- actually let me ask you his age first. was you born in 1948, by the way? >> guest: no, i'm sorry i look that old. i was born in 1955. [laughter] >> caller: okay. reason was -- i was born in '48. that was when israel published another -- established another nation, as you know, but israel is the topic i think should be on obama's mind tonight as well as the problems in afghanistan and iraq. we think that if you look at what i consider the important numbers, i have his code system that's come up in my research,

the number 48. the 48 refers to the 2012 theory that, you know, it's a doomsday coming. and is there really a concern about a nuclear attack on them, they would simply request the american government to allow a complete removal of all the people there in israel and do it over a, say, three-year period and let 'em move to, say, three of the lowest ranked states and allow them to establish, you know, colonization here in america. >> host: tom ricks, any thoughts? >> guest: well, i agree with the caller on c-span. i'm a huge fan of c-span. i think this might be a better country if we could simply get rid of the commercial news cable channels who i don't think are helping the national conversation. i think this would be a better country if everybody just

watched c-span, frankly, so that's a good starting point. on israel, my concern on israel is i don't understand where they are right now, how they expect to get out of their current strategic plight. i worry about israel. i'm a supporter of israel, but i worry especially about the gaza war. and also, clearly, they have real worries with iran. iran, i think, is the biggest winner in the iraq war. iran has really benefited from the removal of saddam hussein and the weakening of iraq as a state and especially the establishment of a shiite-dominated government in iraq. essentially, what we've done is remove the historic barrier to the westward expansion of persian power. iran has benefited hugely and is more influential in the middle east as a result of the invasion of iraq. this is just another reason the invasion of iraq was a really bad idea. and i think israel, rightly, is

worried by the increased threat presented by iran. you're seeing this right now in interesting ways, i don't know if people generally have noticed it, but i wrote about this in my blog, for example, in yemen there's fighting going on on the southern fringe of the saudi or the arabian peninsula. what you're seeing is confrontation between the arabian states and iran i think because iran is feeling frisky and is extending its influence, and you're seeing countries across the maghreb out to morocco expressing some concern about this. >> host: next phone call, michigan, go ahead. >> caller: hello, c-span. i'm a great admirer of your station. and hello, mr. ricks. with this situation between the taliban, al-qaeda and pakistan, shouldn't our country be concerned about al-qaeda getting hands on pakistan's

nuclear weapons? and if so, why don't they, or is it possible for them to move those weapons to a neutral western european country or even our country? >> guest: i'd love to see that happen, movement of the pakistani nuclear arsenal which is believed to be at least 100 nuclear warheads. i don't think the pakistan government would allow it. pakistan, when we ask about this, assures us, look, don't worry, the components of our nuclear weapons are divided up. they're in different spots. so somebody couldn't simply waltz in, steal one and walk away. the worry is as they confront india on occasion, if they feel they face a crisis, that they might bring those weapons together. so you'd be bringing together weapons components, and these things are always most vulnerable when they're being transported. you bring together the components in a moment of crisis, and when the government is overwhelmed, confused and so

on. that presents a difficult and worrisome scenario. what if the government of india said, we simply can't can allow that to happen, to have these nuclear weapons floating around as they're being moved, and so they intervene at that point? this argument is probably the -- is probably the best argument i know for land mines. as a weapon of last resort what you might want to do if you're worried about components of the pakistani nuclear arsenal is fly in and drop what are called air-dropped mines, i think they're called gator, and drop them in large numbers around the weapons bunkers simply to deny people says to them. now, american mines have a nice aspect to them, they self-disarm after six months so you don't have little kids being blown up 25 years later just by walking around on a field. but in a moment of crisis, that might be the best way to deny

access to everybody is simply drop land mines in large numbers around them. >> host: the associated press is reporting that the official number of troops to be sent over the next six months will be 30,000. what happens next when it comes to deploying troops? how does it work? >> guest: it's going to happen more slowly than people think. it's simply difficult to move a lot of troops into afghanistan very quickly. the basic logistical problems, getting them there, feeding them there, giving them a place to sleep, giving them a mission. so i think you'll see the troop numbers go up relatively slowly. then what you do is you start going out and what counterinsurgency theory calls a kind of oil blot, oil stain approach, oil blot. you try to go in and secure one area, change the nature of life in that small area and then expand it outwards. 30,000 troops is not a lot of troops. so what you're probably going to see is trying to secure major

population areas. afghanistan really has five or six major cities, kabul, kandahar, you try to secure those areas and probably also the so-called host bowl which is a large valley southeast of kabul near the pakistani border. that's where you put most of your troops. the rest of the country you do what vice president biden advocated, you simply say in those areas when we find al-qaeda or taliban activity, we'll try to deal with it with special operations raids or with air strikes. 40,000 troops, the worry of $30,000, 40,000 troops is it's enoughs to cause -- troops to cause trouble but not enough to end it. you will be exposing more troops to danger, your troop casualties will go up. the question at the end of the 12 months is, what do you have

to show nor it? >> host: what do you think the obama administration needs to show for it? what are the measures, the markers? >> guest: the real metrics are certainly not anything military. it's not how many taliban you kill. that's the opposite after what you -- of what you want. you want to make themmer irrelevant. the real measures are quality of life for afghans, are schools open, do people vote, do people feel safe going in and going to market? will people talk to american troops? one of the measures i liked in iraq when i saw counterinsurgency on the ground was were the local people telling american troops about roadside bombs they saw planted? that shows not only that they have the intelligence and they know how to talk to the americans, but that they're not afraid or less afraid of retaliation by the other side. your big worry is you go into an area, you develop a lot of local friends, you don't have enough troops to sustain your presence

there. you pull out and all the people who helped you then get punished by the other side. >> westchester county, new york. nat on the democrats' line. are you there? i think we're going to have to move on to atlanta on the republican line. steve joins us. go ahead, steve. >> caller: yeah, my question was how much do you think the afghanistan war has to do with the oil pipeline in the caspian basin which is operated by the unicall corporation of which hamid karzai used to be a former union call consultant? and i know when the invasion took place, president bush tried to nullify the the contract between the corporation from argentina, and now it's operated by union cal with karzai who used to be a former consultant. i'm just curious how much you

think the war has to do with protecting that oil pipeline. >> guest: there's no question in my mind the iraq war is largely about oil. if this were south america, even if it were vietnam we could walk away from vietnam. the americans shrugged it off. it's harder to walk away from the middle east precisely because of oil. i don't think the afghan war, though, to speak to your question, has a lot to do with oil. there's always these conspiracy rumors, but from what i've seen afghanistan is not exporting a lot of oil and gas. there is gas up in the central asian region, but afghanistan is a very resource-poor country. it actually would solve a lot of our problems if someone would find a lot of natural gas and oil there. >> host: kerry on the democrats' line. >> caller: yes, i'd like to know, i'm familiar with your job as a reporter for the pentagon for "the washington post", and i was wondering through that

experience do you know of any way that the, the u.s. military forces could better use their technological advantage such as with the drones and stuff and the, you know, modern technology or they could use that as an advantage to help them try to get better outcome in afghanistan? >> host: mr. ricks? >> guest: on the question of technology, the answer is, unfortunately, i don't think so. i'm writing a book right now, it's actually the job i'm really doing is writing a history of the last 50 years of american military operations since world war ii. one of the things you see in the american military is a constant inclination to look for technological solutions. we like the idea of fixes through technology. our problem is that frequently the problems are not technological, they're human. and, in fact, we spent, i think, at least $10 billion in the military on finding technological answers to

roadside bombs. and they were at least temporarily successful. could you jam the radio wave that turns on and ignites the bomb? could you somehow detect the bombs better and so on. it turns out the best way to prevent roadside bombs is to talk to the locals and make them feel secure and make it so that they can't, the enemy can't plant bombs. this is what mao see tongue referred to as the sea of the people. if you dry up the sea in which uncertainty swims, he's like a fish out of water. we look for a lot of technological solutions, and we look probably too much for them. one of the great revolutions in the u.s. military was the counterinsurgency theory that you wouldn't solve these wars through technological means, that it really is going to be through human means, through understanding cultures, languages and, honestly, showing a little humility. the beginning of wisdom for the americans in the iraq war was saying, you know, let's ask the

iraqis the best way out of this mess, and i think that will be the beginning of wisdom in afghanistan as well. use the troops to improve security but don't say to the afghans, what's the afghan solution here? there's a little bit of arrogance when we think the only form of democracy is our form, one man one vote, because that's what we've known. i've heard the argument of the afghan form of government, of village councils and so on with consensus is actually closer to the ancient greek form of democracy than our current form of democracy. >> host: the president it's been reported that the president yesterday spent time on the phone talking with other foreign leaders, allied leaders about getting more of a commitment from them for more troops, and the french president has apparently told the president no more troops from france. what's your reaction to that and his request for more troops from these allied leaders? >> guest: my reaction, my personal gut reaction, not professional, is, fine.

the french are always more of a problem than a help. and this has been true since world war ii. i actually was working last night on writing about eisenhower. eisenhower told somebody at the end of world world war ii that s greatest enemy in the world was france. the germans were just part of the problem, but the people who really angered him was the french. of the countries that have been fighting there, the canadians and the british have taken real hits. and i think the australians as well in smaller numbers. that said, the other countries, the other nato countries, the continental european nato countries are really just window dressing. you want them there for political reasons. in many ways they're more on the ground militarily they're more problems than they solve. in fact, what i would expect is an area say secured supposedly in quotation marks by german troops or by french troops what you're going to do is have them

there, their regular troops, you know, talking to local leaders and so on, but when you want to go out and do counterterror, you'll put in american special operations troops to go out and do the raids and, you know, the real soldiering. >> host: one last phone call, new jersey. frank on the democrats' line. good morning. >> caller: good morning. i like mr. ricks for whom i have a great deal of respect to address a number of issues. number one, isn't it true that we are inserting ourselves into an ethic conflict between the pashtuns in the south who are almost half of the population of afghanistan and the rest of the ethnic groups in the northern part of the country which are the us beck, the turkmen, etc. and the pashtuns are really the

fighters of the afghanistan. they've been there fighting for centuries against foreign occupiers. >> host: frank, we're going to take that first point because we're running out of time. tom ricks? >> guest: the caller is correct that there is a real problem there with ethnicity and the belief of the pashtuns that tajics especially have been kind of lording it over them in recent years and that hamid karzai, while a pashtun, is simply a pashtun face on northern alliance, tajic rule. it is a problem we have to address. i think sensitivity to ethnicity is really important. but i also think that afghanistan can be stable and has been stable. it has been most stable when there's been pashtun rule in kabul. and so, yeah, you do want pashtun representation and even leadership in the government, but not taliban leadership, and the question is how do you get that? >> host: to read more of tom

ricks' works go to foreign policy, go to his blog at ricks.foreignpolicy.com. he writes a progress called the best defense, he's also the senior fellow at the center for new american security. we thank you for your time this morning, we appreciate it. >> guest: you're welcome. great phone calls. >> american icons. three original documentaries from c-span now available on dvd. a unique journey through the

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week. host: if you are just joining us, we >> welcome to the national archives. this building since 1935 has housed america's most important documents including the constitution and the bill of rights and the declaration of independence. you were hearing senator charles grassley as he was talking to some of the students here as a way of introduction. there are about 200 students, high school students spending their week many for the first time in washington, d.c., and senator grassley, the ranking republican on the budget and agriculture committee, we appreciate your time. >> glad to be with you. >> brandon keyes is one of the students, ask and we're going -- and we're going to turn to him with the very first question. >> good morning, senator, i'm brandon keyes from dallas, texas. my question is what is the primary reason for the health care debate? >> the primary reason for the health care debate would be two. one, to make sure that everybody

has accessibility to health insurance and the care that goes with it, and the second one is that it be affordable. accessibility is generally given by people that have lower incomes to subsidize the buying of health insurance and to make sure that the discrimination that comes through people being denied health care because of pre-existing conditions to do away with it. and so affordability and accessibility. and basically, that would be for people that, the 47-50 million people that don't have health insurance today. of which i suppose you could probably break that down into smaller groups. there may be four or five million people that could qualify for medicaid that don't have it or children's health programs that exist. there's probably maybe ten million people that have incomes

high enough they could buy health insurance, but they figure they want to self-insure or not have health insurance. so it doesn't mean that all 47 million people necessarily are going to benefit from the legislation, but the goal is affordability and accessibility. >> in your report out by the congressional budget office that basically says for most americans this plan will either keep their premiums at the same level or at a reduced level. only a small fraction, according to the cbo, would see an increase. do you trust the numbers? >> listen, you have to trust cbo because in this city they're like god. when they say something is that way, that's the way it is, and if you don't believe them, it takes a 60-vote super majority to override. they're intellectually honest, nonpartisans so, yes, i give them a great deal of credibility. but here's where you have to read between the line when it comes to that figure.

the ones that have individual policies, not group policies -- in other words, not with their corporate plan but buying individual policies -- will probably see premiums go up 10-13%. but what it doesn't talk about is that there's going to be an increase in taxes, and there's going to be mundy accelerated from medicare -- money diverted from medicare to subsidize people's health insurance so that those premiums don't go up. but, so you've got to take that into consideration that somebody else is paying, some other people's premiums don't go up. but if you were at a coffee shop in some small town in texas or iowa or anywhere else and they were talking about health care reform and i walked into that coffee meeting and said something like, well, do you know the bills before congress are going to increase taxes, they're going to increase premiums, they're going to take

$400 billion out of medicare that's already in trouble and put it into another new health insurance program and that we're not going to cut down on inflation of health care, and i said, and i told 'em that's what these bills do because that's what these bills do, they'd say, well, that doesn't sound like health care reform to me because the word reform means that we're going to level things off. we're not going to continue to have the inflation. and people that don't have health insurance would have it, and nobody would expect premiums for anybody to go up. but they're going to go up, particularly for young people like this group here. particularly males 20-30 think they don't need health insurance because nothing's ever going to happen to them. so they decide not to buy it. but a group of young people, 20s to 30s, are going to see a fabulous increase in health insurance, and they're going to also see a mandate from the federal government that you've

gotta buy health insurance. never before in the 225-year history of the country has a federal government ever said you've gotta buy anything. now, states can say you have to have car insurance, but under the tenth amendment, the states have the power to do that. the federal government doesn't have the par to say you have to do anything. but for the fist time you're going to have to buy health insurance. now, is that right? some people give it a good explanation why it's right. i would say we could set up a reinsurance program that would establish the same goal without the mandate. >> we're in the mcgowan theater named after the late bill mcgowan, the founder of mci, and we're welcoming the students here from the closeup program and also our viewers at home. miles city, montana, next up with senator chuck grassley. >> caller: senator grassley? >> guest: go ahead. >> caller: yes, this is kurt from montana. how are you doing this evening?

>> guest: very good, go ahead. >> caller: my question is, why hasn't there been any discussion of the actual medical costs in the hospital and the doctors. >> guest: okay, you'll have to explain your question a little bit further. i can tell you where there is some discussion of it, for instance, we reimburse doctors and hospitals today on the quantity. in other words, the number of times you go to a doctor, you pay for going to the doctor. the number of times you go to a hospital, you pay for entering a hospital. we don't pay based upon quality. and consequently, we don't get the medicine we actually pay for. so in that context we do talk about treatment by doctors and treatment by hospitals, but that may not be what you're talking about. our goal is to move from reimbursement based on quantity to reimbursement based on quality to encourage the best health care to be given the first time. for instance, you know, people

that leave hospitals generally 20% of them are back in the hospital within 30 days. so to encourage hospitals to do it right the first time and not put people out, we are going to give some encouragement for follow-up care after people leave the hospital because that follow-up care would be a lot cheaper than, than in the first instance not doing it right. >> host: we're going to shift back and forth between the issue of health care, and also the other issue, the president's speech tonight on afghanistan. the question from one of the students here in washington. >> hello, my name is ronaldo, and i'm from dallas, texas. my question is, despite the popular sentiment against the war, why are we still in afghanistan, and why is obama going to increase troop levels? >> guest: well, it'd be a better question for the president because he's the commander in chief, but you can ask me and i have opinions on it.

number one, i think that moved away from 9/11 when 3,000 americans were killed, you know, it's probably we feel safe in america, and we don't think things going on in other parts of the world have much to do with our protection here in the united states. but if you would think in terms of what happened at fort hood, texas, recently, the arrest of a terrorist going from colorado over to new york to do some explosive damages there or the arrests of people in minneapolis that were shipping people over to somalia for terrorist activity. and there's communication between people and this country and terrorist training camps and terrorist leaders in other countries. then you see the immediate danger to the united states. so the president knew of this danger when he was running for president, and the president

said the war in iraq isn't as important as the war in afghanistan. that's really where we've got to give our attention. so the president is sworn in in january, he issues a new, a new set of doctrine for the war in afghanistan in march. they fired the general that was in charge there, they hired mcchrystal. the general says he needs more troops, so i think the president is responding to everything he said during the campaign, what he said in his new plan that he put out in march, the new general he hired to get the job done, and he's all doing it in the sense of protecting americans from what we know happens here and maybe a lot of things that i could tell you that are, you know, classified that i can't tell ya but that there is terrorist activity in the united states and what goes on in other countries has something to do with the protection of americans. and the number one obligation of

the federal government is our national security. the state governments, the local governments do not protect you from foreign intervention. only the federal government does that. and so the number one responsibility of the federal government is to make sure that all of you folks and all 306 million americans are protected. and if the president does not do that and he's stated during the campaign that afghanistan was something to be concerned about, he wouldn't be doing his job as commander in chief. and i think tonight he's going to fulfill that obligation as commander in chief to make sure that americans are protected from terrorist activity that is training people to do damage not only in the united states, but other places as well. >> host: president meeting with 31 members of congress this afternoon, will you be at the white house? >> guest: no. i'm not on armed service, not on foreign relation, and i'm not one of the elected leaders of the republican or democrat parties. i think those are the group of

people that will be there. >> host: next question. >> hello, senator, i'm shelby from dallas, texas. i read in the cnn article that there was a proposal for a tax increase to help, to help fund the war in afghanistan. do you know how much the tax increase would cost the average american who's already struggling in the current recession? >> guest: if there is a tax increase, it will have to go through the finance committee that i'm a member of, and we have not had a meeting to explore that idea, and i don't think we will have a meeting between now and the end of the year to explore that idea. now, next year we'll probably get into some tax legislation. the idea that you suggested came from the chairman of the house appropriations committee with the idea that it ought to be done. in previous wars there's been three sources of revenue. one, borrowing. number two, tax increases. and number three, diverting

money from domestic programs into the war effort. and i would say any one of those three efforts are going to be available to fund this operation as well. >> host: back to reviewers, boca raton, florida. you're on with senator grassley. >> caller: yes, good morning, gentlemen. we passed a pharmaceutical plan. i'm in the medical field. we passed a plan that is a windfall for the pharmaceutical companies. we passed a bankruptcy bill that is a windfall for the credit card companies. we now have a public option on the, on the table, and i have patients who are in their so-called doughnut hole where they are now having to make decisions between eating and buying medication. the republicans during the bush administration -- i remember the

pharmaceutical plan that was a cbo person who, by the name of clark, i believe whose job was threatened because he had the temerity to say that it was going to cost $640 billion as opposed to the $440 billion which pleased the bush administration. now, we have a $1 trillion debt to china during the bush administration and anytime that there is a bill before congress that would help people, we have the republican party comes out with their fiscal responsibility slogans. but apparently, there's no credibility here. and then, sir, may i also add during the time that you were supposedly an honest broker, you went before an iowa audience and indicated to them that there were death panels that would kill grandma, and i believe you also stated, sir, that you, your decision making, i believe this is a quote, is based on -- your governing decisions are based

upon the views of whichever group among your constituents yells the loudest. and, of course, with mr. army and the republican party getting these tea baggers and these other individuals before the, before the congress and congressmen, they yelled the loudest. but, of course, they are nothing more than minions of the republican party's base. i'd like to take your answer, sir, off the -- >> host: thank you. >> guest: he had a chance to make the process of representative government work. representative government's a two-way street. i'm one-half of that process of representative government, you are constituents or the other one-half of that process. and if you're going to have dialogue between those of us elected and those that we serve, he has a one-way dialogue. so he didn't ask any questions, b so there's not much i can comment except maybe a little bit of reaction. for instance, he talked about

the program costing more than, than what the actuaries said it was going to cost and that there was some political repercussions from that. well, this is the only program that i've ever been involved in that has come in under budget by $246 billion. but i can tell that the guy from boca raton doesn't know that. the only program that i know of that doesn't have cost overruns and come in 246 billion under. i don't know how you get that sort of ignorance about a program when the budget office can verify those sorts of things. another thing he brought up was my negotiation for three months to try to get a bipartisan agreement. on health care reform. because senator baucus and i have such a close working relationship. when i was chairman of the committee, he worked with me to develop bipartisan bills, and now he's chairman of the committee, i'm working with senator baucus to do exactly the

same thing. so we met during may, june, july to try to work out a bipartisan agreement. and we just about got there. but september came and the leadership didn't want to wait any longer, so they pulled the rug out from under the negotiations, and it went ahead in a partisan way. but i hope the person from boca raton doesn't think that i would spend hours and hours in 31 different meetings to try to develop a welfare, a medicare reform bill and a health care reform bill without trying to actually get there. >> host: health care and afghanistan are the issues we're talking about, and every year the closeup program brings in high school students from around the country. we talked about this right before we went live, how many of you first time here in washington, d.c.? and you first came as a junior in high school, senator? >> guest: yeah. but only for three hours. they're here for six or seven

days, i believe. [laughter] so they have a real opportunity i didn't have. >> host: and we're in the national archives in the mcgowan theater. who has the next question? >> good morning, senator, i would like to ask you, do you think that the new health care bill takes a socialistic approach to solve our health care crisis? >> guest: i don't think so from the standpoint of everything except the public option. when you put the government in a position of being a competitor, a regulator and a funder, in other words, the bottomless pit of the federal treasury backing it up, then i think it's fair to say that the government is not a competitor, it's a predator. and i believe there's studies by think tanks in this town -- heritage would be one. they say 80 million people would lose their private health insurance because of the public option.

lieuen group is another respected group on health care issues, they say 120 million people would go into the public plan. well, pretty soon if you have that many people going into a public plan, then pretty soon there's no private health insurance left over, and then pretty soon you have a government-run program which then from that standpoint would be socialist. and i'll give you an example of two democratic congressmen in this town that have spoken to this issue better than i can and say what their goals are. barney frank, chairman of the banking committee, made statements about a public option is a necessary step to getting to a canadian-style single-payer government-run program. and then a congresswoman from chicago was on youtube here during the summer. they captured her, she was

evidently speaking to a group in her constituency that wanted a canadian-styled single-payer plan right now, and she said to them -- and they were mad about having to go the step of a public option. well, she said, you can't go from here to here, the american people won't move that was to a government-run program, so a public option is a necessary step to get to the government running everything. and so what's socialistic about it and bad because if you ask canadians, you know, they're used to their system of rationing of care and denial of care. for instance, you've got to wait three months for an mri in canada. you don't have to wait that long in the united states, as an example. so do you want that type of health care in america, and i think most americans don't, although there is a group in the senate that would like to have canadian-styled health care right now. i happen to believe that

americans want choice, they want -- they don't want denial and delay, and that's why we're trying to do things, build on what we have now instead of destroying what we have now. >> host: we'll go to john who's joining us from millford, pennsylvania, with senator grassley. good morning, john. >> caller: yes, hi. good morning, senator. hello? >> host: yes, please go ahead, we can hear you. >> caller: good morning, senator. i know you've been concerned with during the health care debate with the possibility of some sort of socialism creeping in, but i'm noting from your biography that you've been working since 1952 in some form of government capacity both in iowa in the house of representatives and the congress -- >> caller: does that biography say that i spent 50 year z as a farmer as well? >> caller: well, i was going to ask you whether you're getting any subsidies or whether -- >> guest: yes. i participate in the farm

program. because i form 50/50 with my son, and you divide things 50/50, yes. >> caller: for over half a century in some form or another. >> guest: yeah, i've made -- for the first 16 years i made $3,000 every other year as a state legislator. now, do you expect me to live on $3,000 every other year? no, i was a factory worker for ten years, and i was a farmer for that period of time. and farm with my son now. so if you're trying to make a case that i lived off of the public tit all these years, i think you're saying correctly the years i've been in the congress, but not before -- >> caller: well, my dad spent a lot -- don't you know the lewin group, you keep injecting them. >> guest: yeah, i quote the lewin group because democrats do, and i think it's a bipartisan respect and it's

quoted by both parties, then it's legitimate for a republican to quote from 'em. senator widen used them to cost out his bill, a democrat from oregon. >> caller: they're owned by an hmo. >> host: thank you, caller. next question here in the audience. >> good morning, senator. i'm from san antonio, texas, and my question to you is, should congress withhold or increase funds for the military in afghanistan? >> guest: did congress what? >> should it hold or increase funds for the military in afghanistan? >> guest: yeah. every dollar spent on anything in the united states government has to be appropriated by congress. every dollar. so any money spent on the military in afghanistan, iraq or any place else in the world is appropriated by congress. yes. >> host: we'll stay -- another question right up here. go ahead. yep.

>> [inaudible] >> host: we'll get you a mic over there. do you think that the health care bill, the senate will pass the bill by the end of this year? >> guest: if 60 democrats stick together, anything can happen because that's the magic number, 60 votes. and the question is, will they stick together? right now there's a half a dozen or so that have some questions about the, some parts of the bill. and the extent to which they stick together will make a difference. >> host: what one question do you have, what worries you the most about this legislation? >> guest: it doesn't have medical malpractice reform in it. we've got a lot of frivolous lawsuits against doctors. doctors will give you every test under the sun because they think you're going to sue 'em. that's called defensive medicine. it adds up to about 10% of the cost of medicine. take 10% of 2.3 billion, you've

got $230 billion being wasted, so we need medical malpractice reform. and at my town meetings around iowa, the one thing that always came up of people that were questioning the direction of congress, not the questioning of should we do something about health care reform, it always came up why don't you do something about medical malpractice, these terrorist louse lawsuits? -- frivolous lawsuits? because people understand that that's driving up the cost of medicine needlessly. >> host: back to the students, all part of the closeup program here in washington this week. go ahead. >> hi. my name is molly, and i'm from here, d.c., and my question has to do with money since you're on the finance committee. so the bill passed in the house with 400 billion coming from medicare, and in the senate it's now up to 500 billion. the white house has made statements saying the cost is necessary and effective, and in your opinion, do you agree with that and how much should the government be willing to take from the medicare program and

what needs to happen to reach that number? >> guest: well, our view is that medicare is about broke anyway. you shouldn't take 400 billion out of it to set up a new program that, that medicare has enough problems of its own, leave it alone. and so that's where we're coming on medicare. you just shouldn't take money out of medicare because it's broke already. >> host: another question over here. >> good morning, senator. i'm jessica from new orleans, louisiana. senator, since the health care plan requires virtually every person to buy some type of insurance and a majority of the people in the united states cannot even afford insurance and are turned down by insurers, how exactly would the federal government aid the american people? >> guest: yeah. well, they would, they would increase taxes, take money out of, out of medicare and, number three, increase premiums. for other people in a way that

brings in money, and i think it adds up to about $700 and some billion out of the total pot of money that's coming in, and that would be used to subsidize health insurance for people under 400% of poverty. so if you're under 400% of poverty, the lower the more money, the higher the less money. but under 400% of poverty you would get some help from the federal treasury to buy health insurance. >> another question in the back row. >> good morning, senator. my name is katie from san antonio, texas. my question is, in respect to the public option, does the u.s. government have a duty to make health care accessible and affordable for everybody in the country if we run a capitalist system which allows people to make personal choices on what services they would like to buy? >> guest: well, i think your question is central to this debate and maybe central to the

differences between the two political parties of whether, for instance, the federal government ought to be mandating that everybody buy health insurance. and i think i've made myself very clear on that point earlier when i said in the 225-year history of our country the federal government has never said you had to buy anything. now, states require you to buy car insurance, but states have more power under the tenth amendment, any power not prohibited in the federal constitution to the federal government states can do. and that's where they get the power to do it. the question is, is it constitutional for the federal government to require you to buy something you might not want to buy? i got a letter yesterday from somebody in my state that said, well, since 1985 -- presumably before 1985 they had some sort

of health insurance, then they became self-employed. they said, all these years i've decided to self-insure. why would you make me buy health insurance, and if i don't buy health insurance, i've got to pay $1500 to the internal revenue service every year because i don't want to buy it because there has to be a penalty or else the requirement doesn't mean anything. and kind of stating that it's unpatriotic, unconstitutional. i don't like it and do what you can to stop it. >> host: to our listeners on c-span radio, we're joined by senator chuck grassley on c-span's washington journal, and the students asking questions part of the closeup program at the mcgowan theater at the national archives. joe from edgewater, maryland, good morning. >> caller: good morning, sir, how you doing? >> guest: good morning. >> caller: senator grassley, with all due respect i've been listening to this debate very carefully, and it doesn't sound like you or anybody in the

republican or democratic party is sincerely representing the interests of america. my question to you is, how can this be a serious debate when you guys pretend like eliminating insurance companies and allowing medical care providers to directly compete for patients by offering low-cost and efficient services is a null and void point? when i go to mcdonald's, i can see the price of what i'm paying for on the menu. when i go to get my car fixed, i can see their hourly rate and the price for what it costs for me to get my car fixed. medicine, the practice of medicine is the only business this this country in which no one has an idea what they pay before they go in, and it's absurd that you guys advocate for the insurance companies by claiming everyone needs to be health insurance when we don't

need insurance. we just simply need the law to make what medicine costs available so that we can make informed choices and spend our dollars where we choose. guest: i agree with you. there's a bipartisan agreement that agrees with you, as well, or maybe even a consensus that agrees with you. there are steps in this legislation. although, i would say, inadequate steps. everything the usage should be posted -- everything you said should be posted on the internet and in the doctors' offices. part of the philosophy behind what we call the exchange -- although, this does not deal with doctors and hospitals, but it deals with consumer friendly information on the internet. this is another one of those things where there's not a

republican or democrat difference. i think everybody believes done if we can have a consumer friendly exchange where you can go to buy insurance, you check in consumer friendly language, not the legalese of insurance policies, what the policy >> then you can comparatively shop, and this would be good for the consumer, just like doing what doctors charge and what hospitals charge. >> host: will try to get two more questions. one right back there. >> good morning senator. i am from san antonio, texas. my question is why does the government want to take over health care? why don't they just leave it up to the insurance companies to provide health care? >> guest: first of all, philosophically, i agree with you. but there are some things in the 150 years of the regulation of insurance companies that government can do

constitutionally. and one of those would be to do away with preexisting conditions that is commendation that comes with it. another one would be the big discrepancies that we have between low premiums and high premiums, to bring them closer together. but where those are some things that are wrong with the delivery of health insurance by the insurance companies. or the fact that you can't buy insurance, health insurance across state lines, but you can buy car insurance across state lines. having health insurance sold across state lines would bring more competition into it so that you would get lower prices. all of these things i think fall within the constitutional powers of the federal government to regulate interstate commerce, and can be done and correct some of the things that are done with private health insurance. but where the bill goes too far,

and probably what you are raising your question about, is this public option, whether or not the federal government can be a competitor and still have the private sector and exist. and i guess i believe aced upon heritage and lewin, that they don't, that the private sector will not exist after a very short parade of time. and then eventually end up with a government run program, which would be what you don't want. >> i am and from new orleans. we have been studying the criteria of a just war, and one category includes the benefits outweigh the sacrifice. so my question for you is are sending troops to afghanistan and iraq, do you believe, that the benefit will outweigh the sacrifice of? >> guest: all i can tell you is prior to 9/11 i would've thought anything going on over there would not be worth our investment. and then i see 3000 americans

killed in a very short period of time in new york and washington, d.c., because people over in that part of the country don't like us. and then i look, responsibility of the federal government to protect us, all 306 million americans, that the number one responsibility of the federal government. and if there are things going on in a fort hood or terrorist arrested in denver because he is going to go to new york and blow up things, or last weekend there were suspects arrested in minneapolis because they were shipping young people for terrorist activity somewheres else in the world. and it is a rude awakening that what happens in 9/11 can happen again in the united states. so i think it brings attention to the fact that you ought to stop terrorist training activities and terrorist organizations as they are

killing americans because the federal government's responsibility is to protect americans. so it's all probably developed because of terrorist activity against americans, and our responsibility to protect americans from that sort of activity. >> host: senator charles grassley is the ranking member of the finance committee, republican of iowa. on behalf of the students joining us here, thanks for joining us on c-span. >> guest: i am glad to be with all of you and i hope sometime i see some of you in congress. >> the senate will continue

>> while we wait for the senator return to debate health care, a look at the other store in washington today, the president's speech tonight on afghanistan's strategy. >> host: bob cusack of the hill newspaper joins us this board to outline the president's speech. bob, i want to begin, your headline, obama sets war policy. sam youngman writes in the piece that president are by and large defined by the wars they wait. how will the president be defined by what he says tonight? >> guest: he will be fine because he will basically own the afghanistan war. this is a war he calls a good

war on the campaign trail. earlier this year in february. president obama said 17000 additional troops to afghanistan, and at that time democrats on capitol hill embraced the move. they said president bush did not pay a lot of attention to afghanistan. he was focusing too much on iraq. now the mood is very different because of the situation in afghanistan has deteriorated. so just like president bush wasn't by and large defined by his decision to invade iraq and start the iraq war, that went well in the beginning of course. and then his political capital evaporated as the war went on. and he left office. but this is a key moment in the obama presidency. he has spent a lot of time deciding what course to take, and he is now definitely a war president. >> host: the other headline in that story is the president must

sway doubting democrats to fund troops erdrich will the president be speaking with democratic caucus today ahead of the speech, and all republicans? >> guest: yesterday is meeting with congressional leaders about 30 lawmakers will be at the white house before president obama had to west point. you will be detailing what he will be saying tonight in the speech. democrats on capital, some powerful democrats including appropriations committee chairman david obie has been saying in recent days that the war must be paid for, that noting the present obama said health care reform must be paid for, must be offset. in the afghanistan war, which he says in the range if we're there for eight to 10 years and obviously we've been there since 2001, will cost close to $1 trillion. we should offset that. so he has proposed a tax on wealthy americans to help pay for it. speaker pelosi has noted that there is a lot of unrest in her

caucus with afghanistan and how it's been going. so there's going to be a tough sell for the president. he not only needs to convince republicans to vote for this because republicans said they wanted 40000 troops at least, it looks like president obama will be a little shy of that, but he must convince a fair amount of powerful democrats to go along with his plan. and i think there will have to be some compromise with capitol hill because they are certainly not going to rubberstamp what obama wants. but he may have to concede as far as some of these, whether that is a tax or some other way to pay for the additional troops urged. >> host: what about selling this to the american people? >> guest: it will be challenging because early this year when the initial 17000 troops, poll shows 65 percent of americans supported the war in afghanistan. since then that number has dropped considerably. so he's got to convince -- he's not going to convince antiwar liberals who have been opposed

to the war in iraq and have been very skeptical of the war in afghanistan in recent years that he has got to convince centrist democrats as well as independents who the polls show have lost faith in this war. >> host: and beyond the speech tonight, what will he and folks in his administration, the defense and state department in particular, be doing to not only sell it to the american people but also as you indicated the legislators up on capitol hill? >> guest: there will be a series of hearings later this week. senator armed services committee, house foreign relations committee, and the top officials in the obama administration, all hands on deck. secretary of state hillary clinton is going to be a broad. she canceled that trip your cheese going to be testifying to the defense secretary, robert gates, as well as admiral mike mullen will be testifying. stanley mcchrystal, the top u.s. commander in afghanistan, republicans have wanted him to testify on his recommendation of

40000 additional troops that got leaked to the "washington post" earlier this year. he has not testified that he is expected to next week. so all of these major players in the obama administration will be making the case. and certainly there will probably be some very tense moments with members who don't want this war to continue, or at least want some kind of timeline to get out of afghanistan. speaker nancy pelosi earlier this year, she did not embrace timelines as far as the timetable to get out of afghanistan, which appropriations committee chairman david obie was pushing for. i think that there will be more of a push for an exit strategy and the white house has indicated in recent days that the u.s. is not going to be in afghanistan for ever. so they are seeking some points that they know will come up from members of congress. >> host: and we look for coverage of those hearings here on c-span. go to c-span.org for the schedule. bob cusack, what should viewers be looking for from these hearings?

>> guest: i think is how to handle the difficult questions and how they will be pinpointed on, number one, the cost and how the u.s. can continue to fight and wage these two wars when we are in record deficits, record unemployment, when lawmakers go home, they are not hearing about the war in afghanistan. they are hearing about jobs and the unemployment rate, which is a 10.2%. so how do we continue to wage these wars from republicans, they will be, how would we not when we have not had a terrorist attack since 9/11 on u.s. soil, even though some people say the fort hood shootings was a terrorist attack, but that is still under investigation. so these top administration officials ranging from robert gates to hillary clinton, the michael and are going to be happy, dealing with very difficult questions for both liberals and conservatives. >> host: bob cusack, managing editor of the hill newspaper will be with us for our first

out here on today's washington to. we will come back and talk to you in a few minutes. first, your phone calls. merriman, crisp from independent line. good morning. >> caller: good morning. thanks for taking my call. president obama on his campaign trail said that he would have a clearly defined exit strategy, and iraq. that has not been put into place. in fact, they are just kind of moving the deck chairs on the titanic and moving over into afghanistan. what i find very interesting is being a former veteran of the cold war, the tipping point that basically financially broke, this is a former soviet union was not only the cold war but also afghanistan. it was unsustainable, that area of the world is not a true

friendly geographic area. you are not accustomed to fighting there. we are not. but what i want here tonight from president obama is basically two things. a clear description of what is a measure of success. and how he's going to fund this war. those are the two things. anything else that he has two put to work or put in place is -- i just consider a smokescreen. >> host: let me ask you. what you think is a clear description? >> return now to resume debate on its health care legislation to "the associated press" reports a bipartisan amendment to increase insurance benefits for women through yearly screening gets the first senate vote, possibly today. live coverage of the health care debate continuing now on c-span2. summer was that there was a rude

awakening that a lot of other things that the congress has done to put this country further in debt and then they heard us talking at that time $1.3 trillion, $1.6 trillion for health care, they thought congress had gone bananas. and so everything seemed to focus on health care reform at that particular time, but people were concerned about the economy as a whole. and i think the health care issue not in and of itself was what people came out for but health care was kind of the straw that broke the camel's back and brought attention to everything else, the debt and things that weren't working. and at the same time, they saw the auto industry going into bankruptcy and of course, being bail out or nationalized, as it is. they've seen banks go under. then they wondered about the

health care being nationalized as well. so we've seen our federal debt scwie rocket by $1.4 trillion since this president took offi office. i say "since this president took office," because i acknowledge that there was a trillion-dollar debt in last year's budget. and just this addition comes out to $11,500 per household. so our federal debt now exceeds $12 trillion for the first time in history. already, foreign holdings of u.s. treasuries stand at $3.5 trillion, or 45% of the -- 46% of the federal debt held by the public. and there doesn't appear to be light at the end of this tunnel. i don't want you to take this senator's word for it because we have the nonpartisan congressional budget office and the white house office of

management and budget that have very intellectually honest people working there that aren't politically motivated that tell us really what is what. and this is what they have to say. both have stated that within five years, the obama administration's policies will more than double the amount of debt held by the public. and both have stated that by the year 2019, these policies will more than triple the national debt. so in this context, you would expect congress to be considering a bill that would create jobs and prevent the country from being burdened with a bigger and more unsustainable federal budget. but instead, instead of working to bring the federal budget under control, we have this congress, the majority of it by

60 being democratic, putting forward a bill, this bill before us, this 2,074-page bill that will cost $2.5 trillion when fully implemented. instead of addressing the budget crisis, this bill will bend federal spending curve the wrong way by over $160 billion over the next ten years. and i remember during the summer the group of six under the leadership of senator baucus -- and i was part of that group of six, bipartisan group. we said two things we need to accomplish. we need to make sure that we have what comes out balanced, and we also need to make sure that we do not have inflation of health care continuing to go up, that we would eventually bring it down. and these buys don't do either.

now, i know that people say, well, we do have the ten-year window balanced. yeah, that's technically right, but when you have ten years of income and six years of policy expenditure, you know, it's easy to do almost anything you want to in that ten-year window. but you've got to look beyond that ten-year window and then you have questions about that. so instead of addressing this budget crisis, this bill adds to the federal burden with enormous costs from the biggest medicaid expansion inivit in history and unfunded liabilities from the new federal -- new program. instead of addressing this budget crisis, we're now considering a bill, this 2,074-page bill, that cuts medicare by half a trillion dollars and threatens seniors' access to care. and after the bailouts of wall

street and detroit, a stimulus bill that's led to the highest unemployment in 26 years and federal -- the federal reserve system shoveling money out the door without any accountabilit accountability -- they even object to having the government accountability office check on it -- the health care reform agenda that the democratic leadership has put forward is once again i use these words, kind of the straw that broke the camel's back. now, we have the senator from arizona offering a motion to send this bill back to the finance committee with instructions to report a bill without the drastic arbitrary medicare cuts that are in this bill. i support the senator's motion because it's an opportunity to fix the bill and then come back to the full senate with a better bill. anything that comes back to the senate floor shouldn't have the drastic and arbitrary medicare

cuts in this bill. and deub do you know whaand do g from seniors is this, that i've paid into this medicare bill for all these years, i've paid into it and now i'm ready -- i'm in retirement and congress wants to take that money and establish a new entitlement program for somebody h else other than seniors. so to a lot of seniors, it just doesn't add up. this bill as now written now permanently cuts all annual medicare provider payment updates in order to account for the supposed increases in productivity by health care providers. the productivity measure used to cut provider payments in this bill does not represent productivity for a specific type of provider -- let's say like nursing homes. you would think that if medicare

is going to reduce your payments to account for increases in productivity, it would at least measure your productivity, not an entire group of productivity or not somebody else's productivity but your productivity, and you would be rewarded according to that productivity. or if it wasn't productive, be harmed because of it because you aren't doing the best job you can. but that's not the case. instead, these reform bills would make the payment cuts based on measures of productivity for the entire economy. so if the productivity of the economy grows because computer chips and other products are made more efficiently, then health care providers see their payments go down. what's the relationship? and these permanent cuts threaten beneficiary access to

care. now, the chief actuary, u.s. department of human services, recently identified this threat to beneficiary access to care. he confirmed this in an october 21 memorandum analyzing the house of representatives bill and again in a november 13 memorandum. both the house bill and the senate bill propose the same type of permanent medicare productivity cuts. we have a chart here. now, the chart is related to h.r. 3. here's what medicare's own chief actuary had to say about these productivity cuts. referring to these cuts, he wrote that the estimated savings may be unrealistic, end of quote. in their analysis of these provisions, the medicare's own chief actuary said -- and i

quote -- "it is doubtful that many could improve their own productivity to the degree achieved by the economy at lar large." the actuary goes on to say -- and i quote again -- "we are not aware of any empirical evidence demonstrating the medical community's ability to achieve productivity improvement equal to those of the overall economy." so you've got a $14 -- you've got a $14 trillion economy tod today. you've got $2.3 trillion of that, or one-sixth, related to health care, and you're going to try to do something to the health care aspect, prospect activity measure, harm or benefit, based upon what happens to the entire $14 trillion economy? that just doesn't make sense. now, in fact, the chief

actuary's conclusion is that it would be difficult for providers to even remain profitable over time as medicare payments failed to keep up with the cost of caring for the beneficiaries. so going back to my chart again, ultimately here is the chief actuary's conclusion, that providers who rely on medicare might end their participation in medicare -- quote -- "possibly jeopardizing access to care of beneficiaries." this bill also cuts $120 billion from the medicare advantage program which provides health coverage to 11 million seniors including the 34,000 seniors in my own state of iowa. these drastic medicare cuts will reduce medicare payments for those 11 million beneficiaries by the close -- by close to 50%.

just like a lot of people, seniors struggling financially right now, and these medicare advantage cuts will only make it harder for them to avoid vision care, chronic care management, dental care and other benefits that they've come to rely on, of their own choosing, because they decided to go to medicare advantage instead of staying in traditional medicare. and what they're going to lose if they don't want to stay in medicare advantage and they -- and they aren't going to get the benefits that they got out of it, they go over to traditional medicare, these sort of benefits are not going to be included in traditional medicare. so, you know, the president said during the campaign, if you got what you -- if you got -- want to keep what you have, you can keep it. it won't be true for medicare advantage people. they're either going to pay more, which is contrary to what the president inside his

september speech to the joint session of congress. you're going to pay more or lose benefits. another problem is that this bill creates a new body of unelected officials with broad authority to make even further cuts in medicare. ironically, this body has been renamed the independent medicare advisory board, but it's not really advisory. i would hardly describe this group that way when its so-called recommendations can automatically go into effect even absent congressional action. absent congress going after it. so i want to go to the chart again. the "wall street journal" has a more appropriate name for this group. they call it -- quote -- "the

rationing commission" and described it as -- quote -- "the unelected body that will dictate future medical decisions." these additional cuts in medicare will be driven by arbitrary spending targets and automatically -- and automatic medicare cuts written into the law by this bill. and this bill unwisely makes this board permanent. this bill requires this board to continue making even more cuts to medicare and to do that forever. and if you want to stop it, it will take another act of congress to do it. and, of course of course, this,f sounds like the sustainable growth race, s.g.r., that impacts doctors every year. we always have to correct the mits stakes that were made by passing -- mistakes that were

made by passing the sustainable gross rate that was set. these targets turned out to be unrealistic. now that the flawed formula will cause an automatic 21% cut in medicare physician payments on january 1 if congress doesn't intervene by the end of this year. we all know the challenges that congress faces every year in trying to prevent these medicare physician cuts that are supposed to take place because spending targets have been extended so automatic payment cuts are then just automatically kicked in. we've all heard from physicians in our states about the challenges in providing care to medicare beneficiaries while these payment cuts loom above. this permanent board, then, would cause the same problem for

the entire medicare program, not just, as s.g.r. does, for physician payments. and this is a far bigger threat to medicare program. it will jeopardize access to health care for our nation's seniors on a much, much bigger scale. if this bill is enacted with this permanent board, w we wille hearing from other providers, in addition to doctors, about how they can't afford to treat medicare patients. what's more alarming is that special backroom deals were cut to exempt some providers so that forces even greater -- this forces then because of these special exemptions that were made, it forces even greater cuts to fall directly on the remaining providers. also the congressional budget

office has confirmed that the board structure requires it to take focus on its budget act on premiums that seniors pay for part-d prescription drug coverage and for medicare advantage. i've already spoken about medicare advantage, but one of the things that you hear at this time of the year all the time from seniors, prescription drug costs are going up, premiums on part-d are going up. and then you want to give this advisory commission that really isn't advisory authority to -- to increase premiums that seniors pay for part-d prescription drug coverage? that means higher premiums for -- for some of our most vulnerable populations. another issue that cannot be ignored is the pending insolvency of the medicare program.

the medicare hospital insurance funds started going broke last year. that means more money going out than is coming in from the payroll tax. in the medicare trustees, and remember they report yearly, and they look ahead 75 years -- the medicare trustees have been warning all of us for years that this trust fund is in terrible trouble. and by a certain date, 2017, we bust it. but rather than work to bridge medicare's $37 trillion in unfunded liabilities, and that $37 trillion is that 75-year figure that the trustees give us once a year each spring as they update it. so instead of working to bridge that $37 trillion of unfunded liability, this bill, you know, does what? it cuts half a trillion dollars from the medicare program to fund yet another unsustainable

health care entitlement program. and medicare has a major problem with physicians' payments that could cost more tha than $250 billion to fix. but this bill ignores the problem. instead the proposed legislation assumes that the government would implement the 21% medicare cut scheduled to go against doctors january 2010. as well as additional cuts for -- that are scheduled for future years under that s.g.r. but by pretending the physician payment issue doesn't exist, this bill would leave future congresses virtually no way to restructure medicare -- no way to restructure medicare that would fix this problem. instead this bill diverts medicare resources elsewhere and exert -- ignores major problems

like that one. besides ignoring major problems like the physician payment issue, this bill also ignores the predictions of experts that medicare cuts like is in this bill will jeopardize access to care of medicare beneficiaries. there are no fail safes in this bill that would -- fail safes that would automatically kick in if these drastic cuts caused limited provider access or worsen quality of care. instead congress would have to step in. congress can always step in. but will it step in? and we know how impossible it is to undo this kind of damage. by making this board a permanent program and requiring permanent

productivity cuts, they become part of the baseline in the next decade. they go on cutting, cutting, cutting forever and forever. and if congress ever wants to shut off those cuts, then this is the problem congress faces. you have to come up with offsets to do it. now, the administration can cut and cut and cut or add and add and add. they don't have to do that. but the budget laws require us to have these offsets or to get the famously impossible thing to do -- get a 60-vote margin to overcome it. the congressional budget office has projected that these medicare cuts keep increasing by 10% to 15% each year over the next decade. yeah, you just heard me right. medicare cuts keep growing 10%

to 15% each year beyond the year 2019. those are some pretty substantial cuts in a program that 43 million seniors and people with disabilities rely on for their health coverage. and provisions, like the productivity adjustments and the medicare independent advisory board would drive the increased cuts to the program. this gives you an idea of the damage these bills will do to health care. this is an example of the challenge that congress will face in the next decade if this bill -- this 2,074 page bill becomes law. in the extended period of its life, this bill would give to the medicare hospital insurance trust fund is really a -- an

apparent victory because the drastic and permanent medicare cuts in this bill will worsen health care quality and access. this bill is the wrong way to address a big and unsustainable budget. you simply can't slash medicare payments, spend those funds to start up another new unsustainable government entitlement program and turn a blind eye toward the effect of access and quality. that is why i will support the senator from arizona's motion to recommit this bill and develop a bill without these medicare cuts. i urge my colleagues to do the same. and the reason i urge my colleagues to do the same is because we have an opportunity here to step back just a little ways, go back to the drawing board on bipartisanship and

maybe come up with something that fits in with health care issue affecting the lives of 306 million americans and, secondly, restructuring one-sixth of our economy. that's something i've heard people on both sides of the aisle ought to be done on more of a consensus basis than the partisan road that's going down. it was a road that for the first six months of this year looked very doable, but it never turned out that way. so i get back to just this bottom line: if you're having a coffee club meeting in some restaurant saturday morning in delaware or illinois or iowa, and they're talking about health care reform, and i go in to explain that what we're discussing right now on the floor of the senate is going to raise taxes, it's going to raise

premiums, it's going to not do anything about the inflation of health care costs and we're going to take almost a half a trillion dollars out of the medicare fund to fund a new entitlement program, i would say that unanimously people would say, well, this is not health care reform. it's got to be something else. but we throw around the word reform when we aren't accomplishing the kind of goals that we have set out to accomplish the first six months of this year. i yield the floor. the presiding officer: the senator from illinois. mr. durbin: mr. president, there's a saying in iowa and in illinois that any old mule can kick down a barn door, but it takes a carpenter to build one. i would modify that slightly and say any old elephant can kick down a barn door, but it takes a

carpenter to build one. we are debating health care reform. the american people are following this closely because it affects every single one of us in this room. everyone in the gallery and everyone watching. this is one of the few things we'll debate which you can bet will affect you and your family personally. it's rare that an issue comes before us at this gravity and an issue that reaches every single person in america. it may be the biggest single issue we have ever tackled on the floor of the united states senate. in terms of its scope and its impact on the future of every single one of us. so for more than a year a lot of people have been working hard to come up with a piece of legislation that will have a positive impact on health care in america. it is involved committee hearings. the presiding officer is a member of the senate finance committee. they sat in meetings hour after

weary hour, day after weary day considering amendments. before they produced a bill that is part of what we have before us today. the senator from iowa is part of that same committee. i understand that he met personally over 60 times with democratic senators and a few from his own side trying to see if we could come up with some kind of bipartisan approach. comind him for his good -- i commend him for his good faith effort in doing that. the health, education, labor and pension committee spent more days in deliberation on the bill, considered amendments and adopted over 100 republican amendments to the bill and not one single republican senator would then vote for the bill. not one. one senator, senator snowe of maine, voted for the senate finance committee, one republican senator voted for that version of the bill. what we have today and i want to just slightly modify my friend from iowa's remarks is a 2,074

bill with -- page bill with a one-page add. this is senator reid's amendment as a substitute. 2,075 pages created by these two committees in the senate and a similar endeavor taking place in the house. for at least 10 days now this bill, in its entirety, has been available for public review. i ask anyone interested who wants to read this bill, as every member should, to go to the senate democrat website and if you google senate democrats, you'll find it, and you'll find this bill in its entirety sitting there to be read and reviewed, as it should be. then i invite you, for comparison sake, to go to the senate republican website to look at the bill produced by the senate republican side.

take a look at the senate republican health care reform bill. take a look at what they propose to change the health care system in america. look at the senate republican proposals for making health insurance more affordable. look at the senate republican proposals for dealing with health insurance companies which deny you coverage because of preexisting conditions. take a look for the senate republican approach to pass health care reform and not add to the deficit. and i'm afraid you'll be disappointed. because as the senator from iowa notes, when you go to the senate republican website, there is no senate republican bill. in fact, what you'll find on senate republican website is the democratic bill. so for more than a year while we've labored to produce this moneymental, historic legislation, our republican

colleagues on the other side of the aisle have not broken a sweat to produce their own answer to this challenge facing america. all they can do is come before us and criticize this bill. any old mule can kick down a barn door, but it takes a carpenter to build one. we have been working for over a year -- almost a year to build this health care reform package. and here's what we know. we just received a report from the congressional budget office, which is like the referee up here. this is an agency that takes a look at what we do and tells us whether it is going to reduce the deficit, add to the deficit, reach its stated goal or fail to reach it. it's maddening sometimes to have a separate agency kind of looking over your shoulder, but they do, and they just reported, just yesterday, that this bill will make health insurance more affordable for many americans

and will not add to the costs for many others. i wish it would do more. i wish it would bring down costs dramatically, even more. but for weeks and months we have heard from the republican side that our health care reform proposals would run premiums sky high. turns out they were wrong. this bill that we have produced moves us toward more affordable health insurance. every american who pays any attention to what health insurance costs knows that is absolutely essential. in the last ten years, health insurance premiums have gone up 131% in america. ten years ago, a family of four bought health insurance for about $6,000 a year. now they buy it on average for about $12,000 a year. and in seven or eight years, it will go up to $24,000 a year in premiums, projecting that it will eat up 40% of your income for health insurance in just eight or ten years.

well, that's an impossible situation. we know it is. it's unsustainable. businesses can't offer health insurance that expensive. individuals can't buy health insurance that expensive. and so if we do nothing, we will reach a situation where the current health care system in america will start to collapse. i don't want to stand idly by and let that happen. neither does president obama. he has challenged us to address it and address it honestly. on the other side of the aisle, the senate republicans have not produced a bill, a proposal, an alternative which will make health insurance more affordable, nothing. they come before us in criticism of what we have done and yet they cannot produce a bill. and i would also tell you the same congressional budget office tells us that the bill we put together will actually reduce the federal deficit over the next ten years by at least least $130 billion. this bill, this 2,075-page bill

will cut more deficit than any piece of legislation we have ever enacted in congress. the senator from iowa is concerned about our national debt. so am i. where's the senate republican proposal for health care reform that is going to reduce america's deficit? and incidentally, the same congressional budget office says in the second ten years -- think that far in advance -- this approach will reduce the federal deficit by another $650 billion. i ask the senator from iowa with all his concern about the federal deficit, where is the senate republican bill that will reduce the federal deficit by by $750 billion over 20 years? the answer i'm sorry to tell you is it doesn't exist. they either haven't or cannot write a bill. they are legislators, but frankly they have come here to be critical of what we've done and not offer a substitute or an alternative. there's something else this bill

does. it is a travesty in america today that almost 50 million people don't have health insurance. a lot of these folks are children. a lot of them are people in low-wage jobs with no benefits, and a lot of them are the newly unemployed. 50 million of our neighbors in america who go to sleep at night without the peace of mind of having health insurance protection. in my life, it happened once. newly married, college student, baby on the way, no health insurance. and our baby had a problem, and i ended up carrying for eight years medical bills that i slowly paid off year after year. that goes back many years ago, as you might imagine, but it was troubling and heart breaking to be the father of a child and not have health insurance. to sit at children's memorial hospital here in washington, in the room that was set aside for people without health insurance and wait until my number was

called to bring my wife and my baby in for a checkup. i didn't have health insurance. i never felt more helpless in my life. 50 million americans go to bed each night with that feeling. they don't have health insurance. what does this bill, this 2,075-page bill do about it? it extends the coverage of health insurance, the peace of mind, protection of health insurance to 94% of americans. it is the largest extension of health insurance in our history. where is the republican alternative? it offers coverage for 94% of americans? doesn't exist. they haven't written that bill. they don't know how to write that bill. they do know how to come and criticize this bill, but they cannot produce a bill which covers 94% of americans and provides tax credits and tax assistance to help those americans pay their premiums. if you're making under poverty

wages -- let's say you're making less than $14,000 a year -- and i've got friends of mine in my state who are -- you're covered by medicaid. you don't pay premiums. the federal government compensates the states, pays the premiums. all the way up to about $80,000 for a family of four, we provide credits and help to pay your premiums, as we should because premiums can break the bank, not only for businesses but for families. there's also something we do in this bill that i never hear from the other side of the aisle, and i'll tell you why in just a second. we give consumers across america a fighting chance when the health insurance company goes to war with you. you know what i'm talking about? somebody in your family gets sick. you know it's going to require a hospitalization or surgery and you know the cost is going to go sky high, and you say thank

goodness i have health insurance. you make the claim and the health insurance company comes back and says we dispute the claim, we're not paying. people say wait a minute, i have been paying health insurance premiums for years just for this day, and you're telling me i don't have coverage? it happens thousands and thousands of times each day, and you know why? health insurance companies are profitable when they say no. what are the reasons for saying no? well, you failed to disclose a pre-existing condition when you applied for the insurance, and it turns out that they go to ridiculous extremes to find an excuse not to provide coverage. we also know what happens when you lose a job, you can't take your insurance with you by and large. we know that when your child reaches the age of 24, they are no longer carried on your family health insurance. those are the realities of health insurance companies saying no. i have yet to hear the first republican senator come to the floor and say that is outrageous

and it has to change, we've got to tackle the health insurance industry because the health insurance industry opposes this bill. the health insurance industry believes their profitability and their future depends on saying no. this bill starts saying to these companies you can't say no. based on a pre-existing condition, based on lifetime limit, based on losing your job. and we cover kids through the age of 26. we extend the family coverage to children to that age. and you know that's only sensible because a lot of kids are going to college and getting out without jobs, you want them covered by your family health insurance plan. this bill does it. the republicans have yet to produce one bill, just one on health care reform that takes on the health insurance industry. instead, what they have come to do -- and the pending amendment by the senator from arizona leads with this -- is protect the health insurance companies. the first thing that the motion to commit does from the the

senator from arizona is to instruct the committee, senate finance committee, to protect a program called medicare advantage. this is a great idea for health insurance companies and not a great idea for most seniors or taxpayers in america. allow me to explain. the health insurance companies came to us several years ago and said medicare is a bureaucratic mess, the government can't run these programs, we are in the private sector, we understand competition, let us compete with medicare. well, they were given the right to do that. private health insurance companies were given the right to write health insurance that provides medicare benefits. they said they could do it more cheaply, and in fact some of them did. but at the end of the day, after years after watching them, it turned out these medicare advantage policies cost 14% more

, not less, 14% more than government-administered medicare programs. in other words, we were subsidizing health insurance companies, paying them more for the same medicare coverage people already had received. they loved it. thousands and thousands of americans now covered by medicare advantage, these great subsidies coming from the federal government. talk about an earmark, senator. 14%, what an earmark that is. mr. mccain: yield for a question? since the gentleman mentioned my name, will he yield for a question? mr. durbin: what the basic problem with the senator from arizona's amendment -- i'll yield to you in just a second -- what the basic problem with his amendment is he is protecting these health insurance companies with medicare advantage. first thing he does. he's protecting this subsidy, this big, fat earmark that we put in legislation, 14% bump in premiums is protected by this motion to commit. now, it's understandable that the health insurance companies

want to keep this. it's a sweet deal. they're getting paid for something that they promised us would never happen. they also -- there's a provision in the senator's motion to commit that says that we should take out of here the conflict of interest sections in medicare. you know what that's about? that's when your doctor also owns the laboratory which does your blood test and the imaging center which does the x-rays and says i'm not sure what's wrong with you, but i know there are two things you need. you need a blood test and you need an x-ray. well, maybe you do, maybe you don't. and we say in this bill you have to disclose to your patient that you have a personal financial interest in this laboratory and this processing operation and you have to give them an alternative to shop for another place if they want to. is that unreasonable? it's one of the provisions the senator from arizona wants to take out of here. it's a savings in medicare.

now, that's unfortunate. we've got to do our best to eliminate the waste and fraud and abuse, as terrible as that old cliche is, in medicare. why is it that the same medical procedure offered in rochester, minnesota, to a medicare recipient costs twice as much or more in miami, florida? i think maybe we -- do you think maybe we ought to take a look at that? i think we should. i think maybe there is some price gouging here. i want to know, does that mean we're going to reduce the benefits for someone living in miami? not necessarily, but it means the taxpayers won't be ripped off, medicare won't go broke. we're doing what we need to do to be responsible. so taking money out of medicare means shutting off the subsidy to the private health insurance companies for medicare advantage. it means stopping the selfdealing of some doctors who are sending medicare patients to their own labs and their own

processing companies. it means finding out where the waste is taking place. the senator from arizona says we instruct the finance committee take out those provisions in the bill. keep medicare advantage there with the 14% subsidy for private health insurance companies. don't engage these doctors when it comes to these conflicts of interest. i don't think that's right. it wasn't long ago that my friend from arizona was a candidate for another office, and during the course of his campaign for president, he suggested that we have a pretty substantial cut in medicare and medicaid. in fact, during the campaign, the senator from arizona called for $1.3 trillion in reforms in medicare and medicaid. more than twice as much as we're calling for in medicare. two and a half times as much. douglas holtz eakan, who worked for the senator from arizona,

said that the campaign plan to fund tax credits and their health care proposals with savings from medicare and medicaid. so the idea of saving money in medicare is certainly not something the senator is unfamiliar with. we all understand that there are possibilities for savings that don't jeopardize basic services for seniors. we also understand that left untouched, medicare is going broke. ignoring the problem will make it worse. if we want to put medicare on sound footing, we have to tackle this issue four square. we can't afford these subsidies for private health insurance companies for medicare advantage and we can't afford the waste that's going on in the system today. i might also tell you that the increase in payroll taxes for those individuals making over over $200,000 a year in families over $250,000 a year, that's the increase in the medicare tax is going to be buying five years of solvency for medicare.

so when they talk about our raising taxes, true, at the highest income levels. what they don't tell you is the other side of the coin. the money brought in goes straight into the medicare trust fund to keep it solid. what else does this bill do? this bill starts filling the doughnut hole. you may not know what that means unless you happen to be a senior or have one in your family, but medicare prescription drugs stop paying at a certain point. this bill starts coverage in the doughnut hole, in the gap in coverage that currently exists in medicare prescription part-d. where is the republican bill to fill the doughnut hole? it doesn't exist. at least i haven't seen it. it's not on their web site. here's ours. that's why aarp has endorsed this bill. the american association of retired persons knows this bill is a good bill for seniors. i urge my colleagues to oppose the mccain motion to commit.

first, if we take this bill off the floor, which many republicans want us to do, it will take us days, maybe a week to bring it back to the floor. they want to delay this as long as possible. they want us to fail. they want us to stop. they want us to adopt the senate approach to health care reform, which is do nothing. leave the system the way it is. we cannot continue the system the way it is. this is a responsible bill. it makes health insurance affordable. it reduces the deficit, according to the congressional budget office, covers 94% of americans, finally tackles the health insurance companies for the first time in a long time, and it buys at least five years more for the medicare program. i wish i could compare it to the senate republican approach, but that doesn't exist. any mule can kick down a barn door. it takes a carpenter to build one. i yield the floor. the presiding officer: the

senator from arizona. mr. mccain: mr. president, i regret that the senator from illinois did not observe the courtesies of the senate, particularly when a person's name is mentioned as he continued to mention my name throughout and totally falsifying my position both in the presidential campaign and the position that we have on this side and this amendment. i've always extended the courtesy to the senator from illinois, and i deeply regret that even this comity of the senate is no longer observed. so, i say to the senator from illinois, i regret that you would not respond to a question that i had posed and that you had said "i will respond in a minute." again, even that comity is not observed here. mr. durbin: if the senator would yield for a second? mr. mccain: i will go ahead -- mr. durbin: would the senator yield for a second? mr. mccain: the senator did not provide me the courtesy of

allowing me to respond to a question. now you want me to respond to a question from you? i will display more courtesy than you displayed to me. go ahead. mr. durbin: i apologize. i planned on yielding to you. i'll be happy to yield to you. i always do, and i failed to. i apologize. mr. mccain: well, i guess my questions were, one, the senator who claimed that we had not -- no republican has done anything to curb the health care insurance industry, was the senator in the senate when senator kennedy fought for weeks and months for the patients' bill of rights? was the senator here then? was he engaged in that debate? senator kennedy and i fought for the patients' bill of rights, and the majority on that side of the aisle opposed it. so the fact is that there have been efforts on my part to curb the abuses of the health insurance industry by sponsorship of the patients' bill of rights. second of all, during the campaign, yes, i said that we

could reduce and eliminate waste, fraud, and spending in the -- fraud, abuse and waste in spending, and i said it because of senator coburn's patient choice act, which could save $1 trillion from the states in medicaid savings, $400 billion over the next ten years in medicare savings. i wish that the senator from illinois would examine the patients choice act as proposed by the senator from oklahoma. maybe we would learn something. the senator from oklahoma's bill wants to preserve the best quality health care in america and not eliminate $120 billion to the medicare advantage program which 330,000 of my citizens are enrollees in and like and want to keep. $150 billion to providers, including hospitals, hospice and

nursing homes, $23 billion in unspecified decreases to be determined by a -- quote -- "independent medicare advisory board" as well as billions of additional cuts to the medicare program. there is no relation between what i tried to do in my campaign and what is being done in this legislation, i tell my friend from illinois. i'll be glad to hear the senator from illinois' response. i'll be glad to extend him that courtesy. mr. durbin: i thank the senator from arizona, and i commend him for his work on the patients' bill of rights, which i joined him in with senator kennedy and would do it again. the point i was making -- mr. mccain: you just said no republican had done anything to curb the health insurance industry. the patients' bill of rights certainly would have done that. mr. durbin: my point was that there are provisions in this bill dealing with the rights of consumers against health insurance companies which i have not heard the senator or others -- mr. mccain: that's not what you said. mr. durbin: i would just ask you: do you support the health

insurance reforms in this bill that give patients the right to -- against health insurance companies on preexisting conditions, for example? mr. mccain: my record is very clear advocating for patients and against the abuses of insurance companies across the board. mr. durbin: we thank you for that. mr. mccain: mr. president, i ask unanimous consent to yield to the senator from oklahoma to describe the patients choice act and the way we could truly save money in -- and reduce fraud, abuse, and waste in the system and at the same time preserve quality health care. mr. coburn: mr. president? the presiding officer: the senator from oklahoma. mr. coburn: thank you. medicare doesn't cover everything. 84% of all medicare patients have to buy a supplemental policy now. do you know what kphaeupbg is about -- medicare crank? who set the price on medicare

advantage? the government set the price. the very same people you want to run it now created a 14% premium. the insurance industry didn't set the prices. the center for medicare services set the prices. the government is responsible for that different repbgs. why is medicare -- for that differential. why is medicare advantage important? because the majority of people can't afford to buy a supplemental policy to make them whole. so medicare advantage for 89,000 oklahomans is the only way they get equality with the rest of their peer group that can afford to buy a supplemental policy. and now we're going to take that ability away from the poor seniors in oklahoma, arizona, iowa, illinois, and we're going to say you don't get what everybody else because you are economically disadvantaged, so we're going to give you substandard care and we're going to take more of your income. medicare advantages offer the

things you get with a supplemental policy when you can't afford to buy a supplemental policy. the very idea to say we're going to take that away, when you take that away, you're taking that away from the cheapest program that we really have in terms of peformance, because what medicare advantage does, which their bill and this bill purports to do is recommends and encourages and incentivizes prevention, like the senator from iowa wants to do for everybody. it incentivizes. it doesn't cause to have a prevention exam in medicare advantage. there is no out-of-pocket cost for our seniors who are poor who happen to have the benefit of medicare advantage. you're going to take that away. you're going to destroy it for 11 million seniors. the ability to get a preclearance, a screening exam without them having to spend money on it. now, is there a way to get money out of medicare? yeah, there's $100 billion worth

of fraud a year in it. and according to harvard, there's $150 billion worth a year of fraud in medicare. there's $2 billion worth of fraud. i want to address something else that -- mr. mccain: before the senator continues -- mr. coburn: i'd be happy to yield. mr. mccain: i ask unanimous consent to regain the floor and then be able -- the presiding officer: without objection. mr. mccain: and engage in colloquy with -- i ask unanimous consent to engage in colloquy with the senator from oklahoma. the presiding officer: is there objection? mr. mccain: mr. president -- the presiding officer: without objection. mr. mccain: mr. president, i have to address the situation since i have been accused by the majority leader of changing my position. in 2005, the senate considered the deficit-reduction act of 2005, which called for approximately $10 billion in reduction in medicare costs.

approximately $10 billion. senator harry reid, democrat, nevada, said -- quote -- "unfortunately, the republican budget is an immoral document. let's look at what is in the bill before us. the budget increases burdens on america's seniors by increasing medicare premiums, and we have not seen what the house is going to give us. it cuts health care, both medicare and medicaid, by a total of $27 billion." the majority leader was outraged in 2005 that there should be reductions in medicare and medicaid spending of $27 billion. now -- now the distinguished majority leader, with the white smoke coming out of his office, now says that he's for $483 billion in cuts in medicare. that, my friends, is a remarkable flip-flop. by the way, i might add that senator dodd, who is here on the floor, said concerning this

reduction, this deficit reduction act of 2005, senator dodd said, "for example, this bill cuts funding from medicare and medicaid, which provide health care to poor children, working men and women, the disabled, and the elderly." what a plea. what a plea. senator barbara boxer said "mr. president, i strongly oppose the reconciliation bill before the senate. the bill would cut vital programs for the middle class, elderly and poor. that's why i cannot believe only two months after katrina we have a bill that would cut medicare and medicaid by $27 billion." and the list goes on and on. and now before us we have cuts of $483 billion, including hospice, including hospitals, including other vital programs for our seniors.

so, if we're going to go around and talk about flip-flops, let's look at the rhetoric that accompanied my colleagues on the other side in their opposition to $27 billion in savings, which, by the way, actually only saved $2 billion to $3 billion over five years. so i would ask my friend from oklahoma, does he believe that it is possible to make these cuts, including from the medicare advantage program, and establish a medicare commission that would not over time cut benefits that exist today for medicare and medicaid patients? mr. coburn: mr. president, i would answer my colleague by saying this bill is a government-centered approach, not a patient-centered approach. it's the very reason that we're in the trouble that we're in

today, is that we've had the government making the decisions rather than the patients and the physicians. and will in fact lessen the care for seniors. i gave a speech earlier this morning on the floor that if you're a senior, you should be worried because the medicare advisory commission and the cost comparative effectiveness commission will now decide ultimately what you got. and we have an amendment on the floor which in many ways i support, i would like to modify, about reinstituting what should be the standard for mammography for women. how did we get there? we have a commission that looks at costs and not patients. from a cost standpoint, the task force on screening is absolutely right. but from patient standpoint, it's absolutely wrong. how do we decide the difference?

do we make the difference based on what something costs or do we make it on what my wife, who will soon be a medicare patient, receives? so the question is: will the cuts that are manifested by this bill impact seniors' care? and as somebody who has practiced medicine for 25 years and cared for seniors for longer than that, i will tell you undoubtedly they will have delay, they will have denied care, and 80% of them will be just fine. but 20% of the seniors in this country will be markedly hurt by this bill, because a bureaucracy looking at numbers, not patients, never putting their hand on a patient, will make a decision about what is good for them and what is not. and everything we know about medicine is that's exactly the wrong way to practice it.

because every patient is different. every patient's family history is different. and so when we talk about taking $120 billion out of the medicare advantage program, what you're talking about is decreasing access to some of the most important screening capabilities that many of these people have. and making them unaffordable because they can afford a supplemental medical policy. they can accomplish it. i want to address one other question. the majority whip said the republicans haven't had a bill. during the markup in the "help" committee, i went through point by point on the patients' choice act. the patients' choice act puts patients and doctors in charge, not government in charge. the patients' choice act neutralizes the tax effect to make everybody treated the same in this country as far as the i.r.s. right now if you get insurance

through your insurance company, you get $2,700 worth of tax benefits. if you don't, you get $100. that's really fair. that's one of the reasons why people who don't get insurance through their employer can't afford health insurance is because we don't give them the same tax benefit. we give a tax cut to 95% of americans plus help them pay their share. the patients' choice act incentivizes states to have reform in terms of the tort problem that we have that we know costs at least 6% to 7% more than we've spent on health care than we would if we had a realistic health system. we go after health insurance companies because we do risk readjustment. if you're dumping patients or cherry-picking, you have to pay extra. you have to pay to the very insurance companies that are covering those sick people. so we change the incentive to where aen insurance company is incentivized -- to where an

insurance company is incentivized to care for somebody rather than to dump them. i was defeated at every turn trying to make this and to say that we didn't come with a bill when on a party-line vote in the "help" committee 13 voted against a commonsense bill that didn't increase taxes, didn't increase premiums, covered more people than this bill will cover by 4 million, put everybody in medicaid in a private insurance policy so that no longer are they discriminated against against the doctors who won't take medicaid, take the medicaid stamp off their forehead, and giving them the same access to health care we have. mr. mccain: so does my colleague find it entertaining that the -- that my friends and colleagues on the other side of the aisle who in 2005 as part of the deficit-reduction act, we had to bring in the vice president from -- who i think was overseas in order to break the tie because they were

worried about what senator reid called "immoral" -- the republican budget, "an immoral government document." is the senator aware that the citizens against government waste have come out against this? i ask that a letter from the group be included in the record? the presiding officer: without objection. mr. mccain: many of the seniors in my state, i would ask my colleague, have been very puzzled at the aarp's endorsement of a proposal that would cut their medicare, that it's already been made clear that medicare advantage -- and there's 330,000 of them -- senior citizens in my state -- that are under medicare advantage; that it's been announced that it'll be slashed that somehow aarp is now supporting it. all i can say is, is my friend aware that there's an organization called 60-plus that is working very hard on behalf of seniors to make sure that

they don't lose these benefits? mr. coburn: i am. i would tell the senator again, how are we where we are? how are we where we are when we're going to take programs that are working -- granted, i think medicare advantage could be decreased by -- through true competitive bidding bu c.m.s. -- but c.m.s. doesn't do that. this bill cuts the benefits in half. the extra benefits that medicare patients have by being signed up on medicare advantage that everybody has who can afford a supplemental policy. i want to address one other thing, if the senator would allow me. the majority whip said, don't we want to get rid of conflicts of interest? yes. but his arkt was specious -- but his argument was specious. because the prices set for an x-ray who are a mammogram or a c.t. or a blood test, they are set a by medicare -- they are

set by medicare now. there's no arbitrariness. the government sets the price for every medicare test out there by region. so there's no way to game it, as the senator from illinois said it was gamed. the best reason to have a lab and a doctor's office is so you don't have to wait and come back for another visit to the doctor that charges medicare another $60, because you get the answer right then. we want to eliminate that. so what will we do? there's no cost savings in that. there is a cost increase. because now instead of giving an answer to a patient, you're going to wait after you send it back to the lab and have it come back in. mr. mccain: may i ask the senator a fundamental question here. how does the senator envision that we can eliminate the fraud,

abuse, and waste and institute significant savings -- one of the ways is retain the provisions in this amendment, this motion to commit, that uses the savings from fraud, abuse, and waste elimination to make the trust fund stronger but at the same time preserve the benefits that our senior citizens have earned? how many times have you heard from senior citizens in your state saying, i paid into this trust fund. i paid for my medicare all my life. now it's going to be cut. how is that fair? how is that fair to my generation, the greatest generation? mr. coburn: if yo you take $100 billion a year -- and that's not an exage rakes. even h.h.s. said the improper payments were $92 billion, the inspector general and the g.a.o. both say it is higher than that -- that's on medicare alone f we just captured $70 billion of

that. now, how do you do that? you know how medicare pays now? they pay and then chase. so you submit an invoice. they don't know if it is accurate or not. they pay it. they pay it. then they go and try to get the money back afterwards. how about precertification of a payment like everybody else does that has anything to do with the volume that medicare has? the other way they do it is undercover patients where you put people actively defrauding medicare in jail. less than $2 billion in this whole bill goes after fraud. that's 2% of the fraud per year. we could cover everybody in the country or extend the life of medicare 20 years by eliminating the fraud that's in medicare today. what are we going to do? we're not. we're going to create more government programs and more agencies that are going to be

designed to be defrauded. and so, therefore, the fraud is going to go up, not down. the fraud is going to go up, not down. and we're also going to limit the availability of prevention to seniors. i've read the prevention text in this bill. there's parts of it i absolutely agree with. we know that if we manage prevention and we manage chronic disease, we're going to save a lot of money. but we're not going to save any of it by building jungle gyms and sidewalks. what we have to do is incentivize people, both physicians and patients to get in the preventive mode. we need accountable care organizations. there's lots of things we could do. there's lots of things we agree on. i know that the senator from iowa and i agree on a lot about prevention. but we ought to be saving that money and we ought to eliminate the fraud. you know, if we did nothing in this body except eliminate the fraud in medicare, think what we would have done. think what we would have done.

think what we would have done to the kids that follow. $447 billion spent on medicare. $100 billion in fraud. wheelchairs that have been billed out so many times that they collect over $5 million on them. doctors who submit false invoices, suppliers who split invoices for people who are deceased, and we try to go get that after the fact? there's lots of things we can do. this bill is short on that. you all recognize it's short on it. it's the biggest savings out there. the reason there's not more in it is because c.b.o. won't score it. because we've never demonstrated the capability. one final point: this bill only scores the way c.b.o. scores because it says you intend to do what no

congress has ever done. it says you intend to cut medicare. $460 billion to $480 billion. if you intend to cut medicare, the american people ought to know where you're going to do it and how it's going to affect them. but if you're just doing it for a scor scoring point, the young people in this country ought to know that, too, because where you say you're claimin saving $0 billion, you just adding to the deficit. we don't cut medicare that much. and is it fair to the medicare advantage patients who are poor, don't qualify for dual coverage with medicaid, can't afford a supplemental policy, is it fair to take away the benefits that they have today that we have given them and it wasn't priced by the insurance industry -- it was priced by the c.m.s. -- and say, because c.m.s., the government agency didn't price

it, we're going to take away half your benefits? it is not fair. it is not right. if there's anything immoral, that's immoral. with that, i'd yield the floor. the presiding officer: the senator from iowa. the senator from connecticut is recognized. mr. dodd: mr. president, the senator from iowa is to be recognized. the presiding officer: the senator from iowa. mr. harkin: well, mr. president, i'm sitting here listening to the senator from arizona and the senator from oklahoma go on. i hardly know where to start there's been so many accusations and so many -- so much misinformation, it's hard to know where to begin. i would begin by, first of all, saying that the people that keep saying that we're slashing medicare and that we're going to harm seniors is just totally false. the fact is the bill that we have before us protects medicare's guaranteed benefits, reduces premiums and co-pays for

seniors, ensures that seniors can keep their own doctors, ensures medicare will not go broke in eight years by stopping the waste, fraud, and abuse -- and i might also just say, as a side, every time i hear the senator from oklahoma talking about waste and abuse and fraud in medicare, it sounds like it's all in medicare. mr. president, the waste, fraud, and abuse we're talking about are the ripoffs of medicare by pharmaceutical companies, many of whom have been fined big fines and settled. one of the most recent ones, i think, was for like $1 billion-and-some. one of the largest settlements of a pharmaceutical company that was caught ripping off medicare, insurance companies ripping off medicare, and others. it is not within medicare. it is those that are coming at medicare and trying to plunder it. but that's what we do in this bill. we're stopping that kind of

waste and abuse against medicare, not in medicare but against medicare. we provide new preventive and wellness benefits for seniors. we lower prescription drug costs, keep seniors in their own homes and not nursing homes with the class act and the community choice act that's also in this bill. when they talk about going after medicare, boy, talk about crocodile tears. was it not newt gingrich, the former speaker of the house, leader of the republican revolution, that said he wanted medicare to -- quote -- "wither on the vine?" was it not senator bob dole, the standard-bearer for president in the 1990's, who said, he had fought against medicare and was proud he voted against it? now all of a sudden it seems like the republicans are the guardians of medicare. people know the truth, mr. president.

the american people know the truth. they know it's the democrats who fought for medicare. lyndon johnson and the democrats -- lyndon john s.o.s. was president -- lyndon johnson was the president and the democrats in the house and senate ... if it weren't for them, medicare would never have been passed. every step of the way it was opposed by other friends on the other side of the aisle. now to hear them talk about how much we're going after medicare ... boy, talk about crocodile tears. well, the other thing i wanted to say, mr. president, is that i wanted to correct something that the senator from oklahoma said. he talked about the recommendations that recently came out -- and i'm going to have nor say about this -- more to say about this in a minute -- the recommendations that came out an mammograms. he said the united states preventive services task force, all they did was look at cost.

that's what the senator said, they looked at cost but they didn't look at the people. well, mr. president, the recommendations that come from the united states preventive services task force cannot take into effect cost. cost cannot be a factor. they can only look at scientific evidence, safety, and efficacy. cost cannot be taken in as any factor in their deliberations. so i wanted to set the record correct on that. as i said, there were so many things -- i heard from the other side -- it's hard to know where to start. i see my leader here, senator dodd, who did such a great job in et going our bill through the committee and -- in getting our bill through the committee and getting it in the form that it is in and on the floor. i would like to ask the senator. senator, i know you were here, we were both listening to our friend, the senator from arizona, go on. did -- did it kind of strike you

that what he said was kind of missing the mark a little bit here and maybe not quite what we're doing in this bill, i ask my friend? mr. dodd: well, i thank my colleague. just to set the record, because it is amazing to me in a short amount of time how people can misconstrue events. first of all, to our friend from oklahoma talking about the medicare advantage bill, and he said, you know who sets the rates? the government sets the rates. well, that's true, and that is because when that bill was passed with very few people on this side supporting that bill, almost overwhelmingly on the other side, the requirement under the law -- requirement, in fact, mandated under the law -- that the private plans in medicare be overpaid. and on average, those overpayments averaged 14%, in some states over 50%. the law that was passed here by the majority -- and running the place -- insisted upon the mandates being included. so when you wonder why that occurs today, it's because they require it in the law. secondly, when you talk about

the deficit reduction act of 2005, again, maybe memories fade for some here, in fact, under that bill, children, working families lost insurance they h had. cuts occurred to proper screenings, women lost mammographies, cervical cancer screening was cut, families lost their -- these benefits. there were direct cuts in them here. the difference is today what we're talking about, you don't cut these benefits today. at all. in fact, we're increasing the opportunity for medicare to be strengthened under this bill. there's a vast difference between what happened in 2005 and what's being supported today. and so i just want the -- again, the record to be compleer on this. you know, you can't make these things up as you go along and that's what happened in 2005. it was an abomination and did great damage to people in this country. people lost their insurance. under our bill, 31 million americans will have coverage.

we now know the premiums are going to drop for 93% of all americans. premiums will actually come down, individuals, small businesses, large employers, for five out of six people who have their jobs. those premiums fo come down for those people. compare that, if you will, with 2005 when we actually cut mammography screening, cervical cancer research, assistance in health care for infants and children and women. that all got damaged in that year. not in this bill. that's the difference. and i thank my colleague for yielding. mr. harkin: the only thing i'd say to my friend from connecticut, he said that we in 2005 had made all these cuts in the deficit reduction act. i just want to say for the record, i didn't vote for it. and neither did the senator from connecticut. mr. dodd: absolutely not. mr. harkin: i would just say to my friend, was this not when the republican were in charge and they had a republican president? and a republican house and the senate? that's when they cut through all -- cut only mammograph

screenings and things like that. mr. dodd: that is true and the record is very, very clear to. it's not -- people had the right to do so, that was their choice at the time. but to now try rewrite history somehow that this wasn't -- those cuts didn't occur, just the facts prove otherwise. in fact, they did occur in these areas, and that's why there are those of us here who objected strongly at the time. my colleague from arizona is absolutely correct when he says i said this was going to cut benefits for children and working families and cut screenings and tests for people. it did do that. those of us who made those warnings on that day proved to be 100% accurate. and compare that, if you will, with what we're talking about here today, particularly with reducing costs, reducing premiums, and providing increased access for millions of americans. that's the difference. now, if you vote for the mccain amendment, we're right back to where we were before, right back, which, of course, we all know means premium increases go up by literally 100% in the next seven years. tell that to the average family of four in my state that's paying $12,000 right now, will go to $24,000 in seven years as

opposed to having those premiums be reduced, depending if you're an individual, small business or large employer, by as much as 20%, 11%, or 3%. not to imagine -- not to -- not to, of course, -- to deny, of course, that you're going to also increase the number of people who will be covered under this. the present situation runs the risk of bringing our economy to a -- to its knees if we don't act. recommitting this bill, going back, in a sense, would roll the clock back and do great damage, both to individuals and to our country economically. that vote in 2005 set us back terrible in this country. this proposal allows us to move forward and provide the coverage the kind that people need. i thank my colleague. mr. harkin: i thank my friend from connecticut for pointing that out. i would just say, mr. president, i have a letter dated december 1, 2009, from the national committee to preserve social security and medicare, and it says, "dear senator: on behalf of the millions of members and

supporters of the national committee to preserve social security and medicare, i'm writing to express our opposition to the amendment offered by senator mccain, which would recommit the bill to the senate finance committee. much of the rhetoric" -- "much of the rhetoric," the president and c. esm o.'s letter goes on, "much of the rhetoric from opponents of health care reform is intended to frighten our nation's seniors by persuading them that medicare will be cut and their benefits reduced so that they, too, will oppose this legislation. the fact is that h.r. 3590, the patient protection and affordable care act, the bill that we have before us, does not cut medicare benefits. rather, it includes provisions to ensure that seniors receive high-quality care and the best value for our medicare dollars.

this legislation makes important improvements to medicare which are intended to manage costs by improving the delivery of care and to eliminate wasteful spending." i won't go on and read all of it. it says, "the national committee urnlingsz you to oppose -- urges you to oppose the motion to reexit the bill to the finance committee." cordially, barbara kelly, president and c.e.o. i ask unanimous consent this letter appear at this point in the record. but, mr. president, i wanted to really talk about the amendment before us for a little bit. the amendment that was offered by the senator from maryland, my colleague, senator mikulski. i'm going to have more to say about the bill and engaging perhaps with the senator from arizona and -- and oklahoma in the days and weeks ahead on the structure of the bill itself, but i want to focus on the amendment that's now in front of us. first of all, i am proud that

the bill, the patient protection and affordable care act, makes significant investments in prevention and wellness, because i have long believed that such investments are essential for transforming our sick care system. that's what we have now is a sick care system. transforming it into a true health care system. one that keeps americans healthy in the first place, keeps them out of the hospital, that will keep a check on rising costs in both public and private health care markets. now, it does this in a number of ways. i won't go into all of them. but among the most important is that this bill requires insurance companies to cover highly effective preventive services with no copayments or deductibles. no copayments or deductibles. now, this is critical because we know that all too often people forego their yearly checkups or essential screenings either because their insurance company doesn't cover them or, secondly,

because they have high co-pays or deductibles that make them simply unaffordable. for example, i had a recent conversation with a small business owner in western iowa, for he and his few employees. they have a $5,000 deductible. he recently turned age 50. his doctor said, time for you to get your first colonoscopy. well, he went and found out that the colonoscopy was $3,000. he has a $5,000 deductible. this is all out of pocket for him. and so not being a man of wealth and not a lot of means, trying to struggle to keep his small business afloat, he's putting it off. putting it off. that's what's happening now. but what we say in our bill, these have to be covered without co-pays or deductibles. now, there's been a lot of discussion recently on the coverage of preventive services for women in light of the recent

issued -- recent recommendations issued by the united states preventive services task force. on the mammogram screenings. now, it's been alleged that the reid bill, like the health and finance bills that preceded it, only riders coverage -- only requires coverage of those services strongly recommended by the preventive services task force. now, this simply is not true. under the language of this bill, health plans are required at a minimum -- at a minimum -- to provide coverage without cost for preventive services recommended by the preventive services task force. understand that? it only says that health plans are required at a minimum to coverage at no cost for services recommended by the preventive services task force. but these are simply the minimum

level, not the maximum. the task force will establish the floor of covered preventive services, not the ceiling. no health plan will be prohibited from providing free coverage of a broader range of preventive services, and in many cases, the secretary of health and human services may well require that. that's because our bill gives the secretary of health and human services the authority to identify additional preventive services that will be part of the essential health benefits offered by health insurers on the exchange. the simple fact is, the preventive services task force cannot set federal policy and they cannot deny coverage, period. although there's been a lot of misinformation that has gone out about this. they simply give doctors and patients the best medical information, as i said earlier, not based on cost -- cost cannot be a factor -- based upon science and based upon efficacy

and based upon outcomes. and nothing else. still, i share the concerns of some that the task force has not spent enough time studying preventive services that are unique to women. this was a concern that was raised when the "help" committee debated the bill in committee. at that time, i worked with the senator from maryland, senator mikulski, to include language requiring that all health plans cover comprehensive women's preventive care and screenings based upon guidelines supported by what we call hersa, the health research services association. well, that was not in our bill, it was not included in the merged bill. senator mick's amendment which is now -- senator mikulski's amendment which is now before us, which i've cosponsored, would add that language, would add that language like we had in our committee bill, and i strongly

urge its adoption. now, by voting for this amendment, which i understand we will do in a couple of hours, we can assure that all women will have access to the same baseline set of comprehensive preventive benefits that members of congress and those in the federal employees health benefit program currently enjoy. let me repeat that. if you vote for the mikulski amendment, you will ensure that all women will have access to the same baseline set of preventive services that are enjoyed by members of congres congress -- women members of congress -- and all federal employees, all women federal employees in the federal employees health benefit plan. that's what voting for the mikulski amendment will do. expanding preventive health care is just one of the ways this bill benefits women. again, our health care system is broken, it's expensive, and today, less than half of women

have access to employer-sponsored insurance coverage. think about that. less than half of the women in this country have access to employer-based insurance coverage. now, again, many of these women work for very small businesses. we know that. very small. and they can't afford to provide that kind of insurance coverage. in most states, it's legal for insurance companies to charge women more than men for the same policy. women can pay more than double than men do at the same age, for the same coverage. each year, thousands of women are denied coverage from health insurance companies for preexisting conditions. in many states, a history of hospitalizations from domestic violence is considered a preexisting condition. think about that. a battered woman lives through domestic violence and now can't get health insurance coverage because of a preexisting

condition. being battered. that happens in many states. now, with these options, it's not surprising that more than 16 million women are uninsured in this country. women respect often the health care decision makers in their families. they face difficult choices daily. one-third of women are forced to make tradeoffs between basic necessities an health care. -- and health care. in 2009 more than one half of women reported delaying care because of its high costs. well, today, we have the opportunity to fix these problems. this historic legislation now before us increases access to affordable health insurance, ensures that women's coverage meets their health care needs. we will end premium discrimination against women. we'll end discrimination against those with preexisting conditions. we will prohibit the decision of

health insurance coverage because of an illness. we'll provide more affordable insurance choices through the health insurance exchange. including a strong public option to increase competition an choice. -- and choice. we'll ensure that the policies that families buy are good enough. we'll require that all insurance policies sold in all markets provide adequate coverage for primary and preventive care -- preventive care for screenings, maternity services, and many other services that women and their families need to stay healthy. as has been said so many times before, this bill will extend coverage to an additional 31 million americans currently uninsured. as i said 16 million -- 16 million women in america, uninsured. and so that's why senator mikulski's amendment is so important, so vitally important.

and that's why this bill is so vitally important. we're going to talk a lot about medicare. i see the republicans are -- are focusing on that. although the recent letter i just read to insert in the record from the national committee to preserve social security an medicare says that -- and medicare says that we ought to oppose the mccain amendment. so we'll hear a lot about that. what about the women in this country and what's happening to them? the mikulski amendment begins to address that in a very profound way -- in a very profound way. but then this bill takes it even a step further by making sure that women who -- many of whom work for small businesses, who are sort of in an uncovered pool so to speak, out there by themselves, now they can go on the exchange. now they can get the kind of coverage that they need. they'll have the choices available to them. not just maybe one option, and

in some states, no option much but they'll have different options available. and they'll be able to join with other like women around so that they'll have a bigger pool and they'll have better coverage for themselves and their families. and so, yes, i can honestly say that the health care reform bill before us, the patient protection and affordable care act, is a pro-woman bill. it's not talked a lot about around here. but many of the things that are in this bill will go to ease the -- the dilemma that so many women find themselves in in this country. providing the basic necessities for their children or trying to get health care coverage for themselves. i can tell you so many women that i've met, that i've talked to who have given up on buying

health insurance for themselves. so that they'll have enough money to feed and clothe their kids. women should not have to make that choice. this bill will enable women to not have to make that choice. they'll get the insurance coverage they need at an affordable price with the tax credits in there for low-income women. and they'll be able to have the peace of mind knowing that they and their kids are truly covered with the health insurance that they need. and so i will keep coming back to this time after time as we go through this bill, two things, prevention and wellness. keeping people healthy in the first place. that's a big part of this bill. and if there's one thing, mr. president, that's going to bend the cost curve, it's just that. putting more focus up front on prevention, more focus on keeping people healthy in the first place.

that's going to save us the money in the future. and the second thing that we might well keep coming back to is what this is going to do for the women of america. how it's going to help them and their families to have peace of mind and to have the insurance -- health insurance coverage that they need. with that, mr. president, i yield the floor. the presiding officer: the senator from montana. a senator: i ask consent -- the next four republican speakers be recognized be senator johanns, senator roberts, senator hutchison and cornyn, the democrats to speak in alternate fashion much the next democratic slot will be senator murray and cantwell to speak on the tragic shooting at washington. those senators count as 1 democratic speaker -- as one democratic speaker and following senator roberts, that i be recognized. the presiding officer: is there

objection? without objection, so ordered. mr. enzi: mr. president, i would yield to the senator from nebraska then. the presiding officer: the senator from nebraska. mr. johanns: mr. president, i rise today to speak in support of the mccain amendment. i've been down here for a while and i've listened to the debate on the medicare cuts and you know what strikes me about this debate is that reality sets in. it just simply does. there will be a point at which hospitals, hospice programs, skilled nursing facilities are going to see less money. i mean, that's just simply the reality of what we're debating here today. it's kind of remarkable to me that you could go from a period just a few years ago wher where $10 billion over five years was described as immoral and today we're talking about nearly half a trillion dollars in cuts.

that's going to have a real impact on real programs that involve real people in our states. now, from our standpoint, we try to look a at this in a way that says, okay, if this were to happen -- if, in fact, this gets the votes necessary, what impact will it have on real programs in nebraska? let me just walk down through that, if i might, mr. president. for example, more than 40 billion in cuts from home health on the national level will translate back to the state i represent to the tune o of $120 million in cuts. $120 million. by 2016, according to our analysis back home, 68% of nebraska home health agencies

will be operating in the red. 68%. in rural areas -- in rural areas as high as 80% will have negative margins. and if you lose those services in rural areas, mr. president, they are lost. in fact, they may be lost forever. skilled nursing facilities are already struggling to keep their doors open. i visited -- visit these facilities when i get back home. many of us do. they are already doing everything they can to make ends meet. already seeing them go under in community after community, i visit these facilities and they tell me -- hospice programs in nebraska have been very well received. years ago i might have predicted otherwise. but, in fact, the reality is

that hospice has worked well in my state and i'm guessing in states across the country. a survey reported 100% think access to hospice services is important. the bill cuts $80 billion nationally from hospice programs. how can we legitimately expect little or no impact or just simply attempt to argue it in a way that when 38 nebraska hospice programs are already operating right at margin. any reduction and they go out of business. hospitals will also see negative impacts. let me quote, if i might, from a nebraska hospital association letter. quote, "our 85 community hospitals have a unique stake in this debate. not only are we providers to

care of more than 10,000 patients per day, we're also one of the largest consumers of health care because we employ 42,000 people. hospitals are an economic main stay of the community that we serve and we, the nha -- n.h.a. are opposed to all measures that weaken their stay ability and viability." the nebraska hospital association indicates that disproportionate share hospital cuts will be $128 million. if hospital -- other hospital cuts are factored in, nebraska hospitals say that they will see a total loss of $910 million. now, mr. president, i visit these little 25-bed hospitals. they have no room for error. there is no margin there.

when they lose something like this, they just simply cease to exist and that community then is on its way to ceasing to exist. finally there's very, very clear that medicare advantage is on the chopping block. that's 35,000 nebraskans. no matter how hard you want to argue that, there are 35,000 medicare advantage beneficiaries in my state that are going to experience cuts in the very program that is such an important safety net to them. c.b.o., the congressional budget office, estimates reduced benefits from $135 to $42 a month. the so-called extra payments that would be cut are helping medicare advantage beneficiaries get very valuable benefits. many who utilize medicare

advantage are truly our most vulnerable citizens. we can't ignore that important fact. seniors with a medicare advantage plan might receive vision or dental benefits or have their medicare co-payments reduced. in our state, and i'm guessing this is true of states all across the country, what you see is that some of the poorest actually have medicare advantage. now, mr. president, if you don't believe me, just yesterday i received a letter from -- from hispanic groups and they said this, and again -- quote --"with the growing number of hispanic seniors, one in four who have medicare advantage, the defunding of the medicare advantage program and the other medicare cuts proposed would result in fewer benefits in this

significant disruption in care in coverage in senior hispanic americans and what they receive." and, mr. president, i ask unanimous consent to submit that for the record. the presiding officer: without objection. mr. johanns: mr. president, how could any member go back to their state and defend these cuts to services that provide very important health care needs? americans just simply deserve better than that. if we want serious medicare reform, we should start with true waste and fraud and concentrate on medicare insolvency. especially when we all agree that insolvency arrives in 2017. what we are doing here today in these days of debate, is we are truly robbing from peter to pay paul. and peter is soon to be broke.

unfortunately, that is exactly what we are doing. americans deserve better than the bill that we are debating here today. i can't stand silently and accept a bill that has such dramatic cuts in the services provided to nebraska's seniors. thus i conclude today, mr. president, by saying i support the mccain motion to recommit to remedy these problems, to get us back on track with commonsense reform. i yield the floor. the presiding officer: the senator from washington. mrs. murray: thank you, mr. president. mr. president, we are obviously in the middle of a very important debate on health care, and i want to thank the managers of this bill allowing my colleague from washington state, senator cantwell and i, to interrupt this important debate to talk for a few minutes about a very tragic event that

occurred in our home state of washington over the past weekend. mr. president, just two days ago our state was shocked and saddened and appalled by news of the deadliest attack on law enforcement in washington state's history. on sunday morning just after 8:00 a.m., a gunman walked into a coffee shop in pierce county, washington, and opened fire, killing four members of the city of lakewood police department who about going over the details -- who were going over the details of their upcoming shift. it was a senseless and brutal killing. it specifically targeted the people who sacrifice each and every day who keep all of us safe, our police officers. this terrible crime has not only left the families of these victims shattered, but it has shattered our sense of safety and left an entire community and state in disbelief. it is also part of a shockingly violent month for my state's law

enforcement community that has also included a senseless attack on october 31 which killed seattle police officer timothy brenton and left another officer, britt sweeney injured. these attacks remind all of us of the incredible risks that our law enforcement officers take each day and that even when doing the most routine tasks and aspects of their jobs, our law enforcement officers put themselves on the line for our safety. mr. president, today my thoughts and prayers, like those all across washington state and our nation, remain with the families of the brave police officers who were killed on sunday. officer tina griswald, a 14-year veteran who served in the police departments in shelton and lacey before she joined the lake wad police force in 2004. she leaves behind a husband and two children. officer ronald owens followed his father into law enforcement.

he was a 12-year veteran of law enforcement and he served on the washington state patrol before moving to lakewood police department. he leaves behind a daughter. sergeant mark ranjer. he was a veteran who wore the uniform of the united states before putting on the police department uniform in 1996. he joined the lakewood police department in 2004. he leaves behind a wife and three children. officer greg richards, an eight-year veteran who served in the kent police department before he joined the lakewood department. he leaves behind a wife and three children. mr. president, because of this senseless attack, nine children have lost their parents. these were officers, mothers and fathers, husbands and wives who woke up every day and put on their uniforms and went out to protect our children and our communities and our safety. on sunday, they didn't come

home. already in news reports and internet postings and candlelight vigils, thousands of tributes to these officers' dedication to their families and jobs have been shared. they paint a picture of brave officers who not only keep our communities safe but were also so respected and revered members of our community. a -- mothers and fathers who in the wake of this tragedy will leave young families behind, neighbors and friends who coached softball and helped repair local homes and reached out to help those in need. they're police veterans who helped build the foundation of a new police force. they are public servants who put the safety of all of us behind their own every single day. mr. president, already this year, 111 police officers across our country have given their lives while serving to protect us. each of these tragedies sheds light on just how big a sacrifice our police officers make in the line of duty, but

these most recent attacks in my home state also offer an important reminder -- that our officers are always in the line of duty, even when they're training other officers or out on routine patrols or simply having coffee. mr. president, there is no doubt that these senseless attacks have left many law enforcement officers across my state and our country feeling targeted, but there is also no doubt that their willingness to put themselves on the line to protect us will continue unshaken. in fact, over the last three days, law enforcement officers from all across my state have risked their own lives in the successful search to find the man accused of this killing and to keep him from hurting more innocent people. that is a testament to the unwavering commitment they make to serve and protect each of us every day, and it should remind all of us that these brave men

and women who deserve all the support that we can provide to keep them safe. mr. president, no words are adequate to express the shock, the anger, and the disbelief that comes with such a brutal crime, and no words will be enough to lessen the loss. our law enforcement professionals put themselves between us and danger every day. right now, in light of such horrible events, we hold them even closer in our thoughts and our prayers. mr. president, i yield to my colleague from washington state, senator cantwell. ms. cantwell: mr. president, i rise today to join my colleague senator murray to express my sorrow over the tragedy that has struck washington state and the law enforcement community. i want to extend the prayers and condolences of the senate and the entire nation, to the families, loved ones, and colleagues of the four police officers that were killed and

lost their life in the line of duty sunday in lakewood, washington. those four officers, part of washington's best, sergeant mark renegar, officer ronald owens,ster tricia griswald, officer greg richards, collectively they served for 47 years in the line of duty, and as lakewood's police chief described them, they were outstanding individuals who brought a range of talents to a 5-year-old department. these heroes who put their lives at risk for our safety every day will be deeply missed and never forgotten. the men and women who keep our communities safe make tremendous sacrifices daily, and so do their families. the senseless tragedy that claimed the lives of these four officers, as my colleague said, the deadliest attack in washington state history, reminds us that the risks that police officers take every day

when they put on their badge. mr. president, the risks that police take every day was driven home again today when a seattle police officer on routine patrol confronted, shot, and killed a person believed responsible for this crime, and at a time when we are all in shock over the loss of these officers, the police remain vigilant. they didn't stop doing their job even when tragedy struck close to home. i want to thank all those who have participated in the law enforcement's response to this since the tragedy has happened. i want to thank the pierce county sheriff's office and sheriff paul pastoor for the investigation that they have led and my heart goes out to the lakewood police department and the chief. i would also like to thank the efforts of the seattle police department and the interim chief john diaz for his efforts and

their agency's work. mr. president, in a matter of days, police and public safety officers from all around the country will converge on puget sound. they will form a long blue line in a show of respect for those who have fallen -- mark renegar, ronald owens, tina griswald and greg richards. this moving ritual which happens all too often in our country speaks eloquently of the solidarity all of us feel for those who risk their lives to keep us safe. as my colleagues -- colleague said, this tragedy struck our state more recently -- in october when officer timothy britton was struck down randomly while sitting in his police car. so, mr. president, i hope that those in this country will take time today and and -- and tomorrow and next week if you see a police officer, just thank them. thank them for their service,

express our appreciation for the job that they do at putting themselves at risk for all of us. we didn't have enough time to thank mark and ronald and tina and greg, but we are thanking them in our thoughts and prayers, and we are sending strength to their families with much love and appreciation for what those and their family have done to serve us in our communities. i thank the president and i yield the floor. the presiding officer: the senator from montana. mr. baucus: i think mr. roberts is recognized. the presiding officer: the senator from kansas. mr. roberts: i thank the distinguished senator from montana and my chairman of the finance committee, mr. president. let me say first in behalf of the senators from washington state that i think all senators

appreciate both senators bringing to the attention of the senate the heartfelt feelings in regards to the tragedy that happened in their state, and i share -- i share their dismay in regards to what has happened, and i know that the thoughts and prayers of all senators are with them and i appreciate the remarks that they have brought to the body at this particular time. mr. president, i would now like to discuss briefly this motion to recommit in regards to medicare and the tremendous cuts that are proposed in the bill, the bill i define not as the finance committee bill, not as the "help" committee bill, but the bill that was really done behind closed doors which i think was most unfortunate. this bill slashes -- and i think that's the appropriate word --

nearly half a trillion dollars, half a trillion dollars from medicare, and then it is used to establish a huge new government entitlement program. now, earlier this year, during the finance committee markup of health care reform legislation, i offered a nearly identical amendment to the mccain motion to recommit that we are now considering which is a motion simply to send the legislation back to the finance committee with instructions to strike the cuts to medicare in this bill. unfortunately, my amendment back during that time failed in that committee on a party-line vote. let me see if i understand this correctly. medicare is going broke. it has around $38 trillion in projected future unfunded liabilities. it is a huge, crushing entitlement program that threatens to bankrupt this

country. but instead of owning up to this enormous threat and doing something about it, to our financial future, instead of considering a medicare reform bill to address this menace to future generations of americans, instead of guaranteeing that the government-run plan that we currently have remains solvent, instead, we are actually cutting some $465 billion from medicare in order to start a brand-new, huge crushing entitlement program that makes no sense. if medicare needs to be reformed -- and i certainly believe that it does -- then we should be considering a medicare reform bill right now. we certainly should not be cutting medicare for the purpose of financing a huge new entitlement program. now, my friends on the other side of the aisle have really the temerity -- that's a pretty strong word but i think it

applies -- to assert that these huge cuts will actually make medicare more solvent. nothing could be further from the truth. i have news for you. cutting reimbursements to doctors, cutting reimbursements to hospitals and other providers, all providers -- and it's been mentioned by my distinguished colleague from nebraska, home health care providers, hospices, this is not reform. these cuts will hurt medicare beneficiaries, our seniors who have worked their entire lives with the promise that this program would support them through their older age. medicare already pays doctors and hospitals well below cost, 70% approximately for hospitals, 80% for doctors, approximately. the only saving grace is that these providers have the ability to shift their losses onto private payers to keep their doors open or their practices that would keep going. but there is a limit to their

ability to cost shift. there is only so much the private sector is willing to absorb, and american families already pay -- now, get this -- an extra $90 billion in a hidden tax to make up for the medicare and medicaid underpayments that we in past years have provided each year. more cuts to reimbursements coupled with a massive increase to medicaid this bill assumes will push these limits, meaning that fewer doctors will open their doors to fewer medicaid patients -- they're doing that right now, we're rationing right now, access to doctors that accept medicare patients -- and access to health care for our seniors will be compromised. take the $105.5 billion cut to hospitals just as an example. i know that the national hospital organizations have

signed off on these cuts. i don't know why, but they have signed off on these cuts. i also know for a fact that they will harm kansas hospitals. i asked my kansas hospital association -- i did at my request -- to run the numbers on how this bill will affect their bottom lines, and their findings are frightening. according to kansas association's outside experts, this bill will result in nearly a $1.5 billion loss in kansas hospitals over the next ten years. it may be true that some urban hospitals that currently have large percentages of uninsured patients may have some of their cuts offset by the potential reduction that this bill will make to the uninsured population, but that is no consolation to a hospital in

mcferson, kansas, for example, that may be too large to qualify for the higher reimbursements allottable for what we call critical access hospitals and has, unfortunately, the mismore tune of serving a larger than average uninsured base. this bill's $100 billion cut will only hurt these hospitals and their abt to serve -- ability to serve medicare and even non-medicare patients. remember the cost shifting. medicare's own actuaries at c.m.s., center for medical services -- sofrt an oxymoron -- have agreed that the democrats' cuts to hospitals and other providers could be dangerous and could cause them to end their participation in medicare. so why are we doing this? another huge cut to medicare in this bill is that $120 billion cut to the medicare advantage

program. my distinguished colleague from nebraska has already talked about that, the effects of medicare advantage to nebraska. let me talk to kansas. close to 11 million or one-quarter of medicare beneficiaries are enrolled in medicare advantage. 40,000 of those beneficiaries are in kansas. i want to read an excerpt from one letter i received from a very satisfied medicare advantage customer, seanee kansas america. miss lilla jay colette writes, senator, please, use everything in your power to let me and the many, many other people in kansas who have chosen, they have chosen humana gold plus to keep this wonderful plan. miscolette is not alone. satisfaction rates are extremely high. i know they're very unpopular to the other side and there is a lot of allegations made but

these people made that decision on their own. so why are we essentially gutting this program that provides quality and choice to our seniors? i could go on about the cuts to hospice, home health care providers, nursing homes, but i think you get the point. i disagree with the failure to prioritize the solvency of medicare over the establishment again of new government programs, and i certainly will never agree to financing these government expansions by bleeding the medicare program dry. that's why as i have said, i offered amendments in the finance committee markup that would have struck these medicare cuts. again, unfortunately, they were defeated on a party-line vote. now, as the president is fond of saying, let me be clear, this bill is funded on the backs of our seniors, and those that provide medicare to our seniors. this bill slashes medicare by $500 billion. this bill threatens access to

care for seniors and health care for all americans. i hope that my colleagues will join me in opposing these cuts by voting for the mccain motion to recommit. now, this is a key vote. don't kid yourself. this is the key sroefplt you are either -- key vote. you are either for protecting medicare or not. mr. president, i yield the floor. mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: mr. president, i'd like to once and for all hra*eu once and for all lay to rest this false claim that the pending bill is going to -- quote -- "hurt seniors and it is going to hurt providers and it's

going to be this long parade of horribles that the other side likes to mention. it is totally, patently untrue, the claims that they are making. number one, all the crying, allegations on the other side that the underlying legislation cuts medicare, it cuts medicare, cuts medicare. that's what they say. what they don't say is that it does not cut medicare-guaranteed benefits. it doesn't cut benefits. it does reduce the rate of growth that hospitals would otherwise receive. it does reduce the rate of growth that medical device manufacturers might receive. all that is true. so it is true that it is cutting the rate of growth of medicare providers. it is not true that this

legislation cuts medicare benefits. that is not true. the other side would like you to believe that's true by using the words they choose, by saying cutting medicare. they want you to believe that's cutting medicare benefits, but it's not cutting medicare benefits. rather, it's -- the underlying bill reduces the rate of growth of government spending on providers, on hospitals, home health, hospice, lots of other providers. that's really what's going on here. don't let anybody fool you, this bill does not cut medicare benefits. it does not. it does reduce the rate of growth of providers. now, why are we doing that? first of all, most of these providers, virtually all the providers say, gee, we don't like our rate of growth of

federal dollars coming to us being cut, but we'll go along with it. they're okay. they're okay with it. why are they okay with it? why is the american hospital association okay with reducing the rate of growth of hospital paeupts by $-- payments by $155 billion stphr why why are they y with that? because they are going to make it up on volume. they're going to have health insurance. americans who do not have health insurance now often have to go to the emergency room of the hospital, the hospital has to provide the care. it's uncompensated care. nobody's paying for those hospital benefits. and that cost is transferred off on to private health insurance premium holders. they've got to pick it up. on average, that's about $1,000 per family per year. so, number one, let me repeat, there are no cuts to medicare

benefits. there are reductions in the rate of growth to medicare providers, which the providers agree with by and large. i won't say totally. i won't stand here and say they're jumping up and down and they're enthusiastic about it. but i am saying that they realize they're really not getting hurt. they're going to do okay. they're going to do okay because they're going to make up on volume that they might otherwise lose. that is a very important point for people to understand. second, if you listen to the other side, what they would have us do is virtually do nothing. and what does doing nothing mean? doing nothing means that the solvency of the medicare trust fund is just over the horizon. this legislation extends the solvency of the medicare trust fund another four to five years.

man, oh man, if i'm a senior or about to be a senior, i would sure like the medicare trust fund to be solvent. i would like that very much. this legislation extends the solvency of the medicare trust fund by another four to five years to about the year 2017. so without this legislation, the actuaries say the medicare trust funds can become insolvent in 2012, around there somewhere. that's not very many years from now, mr. president. not many years at all. it's very important we extend the solvency of the medicare trust fund. now you might ask, why is the medicare trust fund in a little bit of jeopardy? why is that? why is that? the very basic reason is because health care costs are going up at such a rapid rate in america, at a very rapid rate in america. our health care costs are going up 50%, 60% more quickly than

the next most expensive. we already pay per capita 50%, 60% than the next most expensive country. there is a whole host of things in this legislation to make sure we have some limit over health care costs. mr. president, i realize i misspoke earlier. currently the medicare trust fund is due to be insolvent in about the year 2017. this legislation extends the sol veteran sift medicare trust fund to the year 2022. so the principle is the same, but the five years is tacked on a little bit different later period of time rather than up front, so early. but we're doing a whole host of things in this legislation to reduce the rate of health care costs in this -- to people in this country, and it's health care costs which are driving up the cost of the medicare trust fund. and so we're doing all we can here to extend the sol veteran

sift medicare trust trust fund. some might say baby boomers are retiring more, that is going to add to the pressure on medicare. that is somewhat true, but the congressional budget office did a study six to eight months ago which i think it is about 70% of additional costs of the medicare trust fund is due to cost increases. it's not due to more baby boomers retiring when they reach the age of 65. what do some of the groups say about this legislation? let me just say what aarp says. i have a chart here which indicates what the american association of retired people says about the underlying bill. if they were cutting medicare like the other side says, you'd think they wouldn't like this bill. aarp hasn't totally endorsed this bill but they don't have problems with it because they know we're doing the right thing. what do they say?

aarp says opponents of health care reform won't rest. they're using myths, misinformation to distort the truth and wrongly suggesting that medicare will be harmed. after a lifetime of hard wor don't seniors deserve better? that's what the aarp says, referring to the distortions and misrepresentations and untruths, trying to scare seniors mentioned by opponents of this legislation. here's another aarp quote. "the new senate bill makes improvements to the medicare program by creating a new annual wellness benefit, providing free preventive benefits and most notably for aarp members, reducing drug costs for seniors that fall between the dreaded medicare doughnut hole that causes a gap in the prescription drug benefit." it's a very important point, mr. president. this bill not only does not cut benefits, it increases benefits for seniors. what is referred to right there, and that's the so-called

doughnut hole, the gap in coverage under the prescription drug program, this legislation in effect says that seniors now will have $500 of their drug benefit, prescription drug benefits paid for when they're in that doughnut hole period. and add to that, this bill also says it's all paid for, at least for one year in this doughnut hole. we may have to worry about that in subsequent years but this bill improves the benefits seniors will get, not take away benefits as the other side would imply. now it is true that private programs like medicare advantage are reduced from what they otherwise would be, just as hospitals are reduced in payments from what they otherwise would get. let me just -- i have a chart here. let me point out the next chart here if i could, which shows that the provider groups, hospitals, et cetera, are actually going to do okay under

this legislation. what does this chart show? this chart shows that medicare spending will continue to grow under this legislation. it will grow, and grow by a lot. here it is in 2010, it is $446 billion. you can see a steady growth in ten years of this bill. and i might say that parenthetically one of the previous speakers said rural health care is going to be hurt, rural hospitals are going to be hurt by this legislation. mr. president, i don't think that's entirely true. i've got a lot of hospitals in my home state of montana, pretty rural hospitals, they say it's okay. they approve it. in addition to that, there is no disruption to critical access. in rural areas most of those hospitals are critical access. so they're going to be okay. basically if we do not pass this legislation, these provider groups, hospitals, nursing

homes, home health, hospice, medicare advantage, even part-b and medicare improvement would all increase by about 6.5% over the decade. they would all increase by 6.5% over the decade. under this legislation, they all increase by about 5%, by 5% over this decade with a 1.5% cut, which they basically agree to. so i want to make that point very clearly, mr. president. we're not cutting medicare here. not cutting medicare benefits. not cutting medicare benefits, but we are reducing the rate of growth of medicare spending. now, another point i want to make here if i could, mr. president, is that there's nothing new here. many of the centers advocating killing this bill -- many of the senators advocating killing this bill made the obvious statement not too many years ago. what did they say?

you have to reduce the rate of growth in medicare spending in order to save medicare benefits. that's what they said a few years ago, exactly what they said. let me read from some. "we propose slower growth of medicare. medicare would otherwise be bankrupt." they're making the opposite statement today. the exact opposite statement today to try to scare people to kill the amendment. here's another senator. i am not going to embarrass them by giving their names. but they are senators who currently serve in this body. here's another one: "we do heed the warning of the medicare board of trustees and limit growth to more sustainable levels to prevent medicare from going bankrupt in 2012."

that's what they said. experts know that if we're going to save medicare benefits, we've got to stop overpaying some of the providers, hospitals and so forth. and we are overpaying them. let me tell you one small example of how we're overpaying them. did you know that the updates -- there's just a fancy term for paying more for hospitals and so forth -- did you know they don't take productivity into account when they make these recommendations? the recommendations are based by an organization called medpac. as the presiding officer knows, medpac is a bipartisan organization, it is a nonpart isn't organization composed of doctors and experts that advise congress on what the payment updates -- what the payment increases should be for different groups over the years. and we in congress basically look at them. we try to decide what makes sense, what doesn't make sense and so forth. but medpac has said, mr. president, that this is what we have to do. we've got to slow the rate of

growth of some of these providers because they're getting paid too much. they're getting paid more than they need to be paid. and i just said -- i'll repeat myself. we're going to allow still a 5% growth over the next ten years and none of them are really crying wolf, i might say. the -- that's the main point i just want to make, mr. preside mr. president. i mention what aarp is saying. let me mention the american medical association. "we are working to put the scare tactics to bed once and for all and inform the patients will the benefits of health reform." that's the american medical association. they are referring to the scare tactics of the other side. so the aarp and the american medical cal association and others know that no senior will see a single reduction in guaranteed medical benefits under this bill, not a single

one. i might also say that this bill would reduce premiums that seniors would have otherwise paid. much of those savings come from limiting massive overpayments to private insurers -- that is, private companies like medicare advantage. seniors hear the word "medicare advantage," they tend to think that's medicare. it's not. it's a private company. those are private companies. and they're basically enhanced under the 2003 medicare part-d legislation. they're give an lot more money to encourage them to have competition in rural areas t turned out that we gave them way too much additional money and they know it. and this legislation is trying to cut back on the excess that they're provided back in the year 2003. i might say the cut is about $118 billion over ten years. i don't have with me how much is remaining, but that 5% figure i gave you of growth, that includes medicare advantage

plans. i mention already that this legislation would reduce prescription drug costs. that doesn't sound like a benefit cut to me. it sounds like an additional benefit for seniors. and we also provide for new prevention of wellness benefits in medicare. that's in addition. that's not a cut. that's an addition. we're also helping seniors stay in their homes and not -- their own homes, not nursing homes. that's a benefit. i think it is important to point out here, the opponents of health care reform do not have a plan to protect seniors and strengthen the medicare program. they say, don't do what they said a few years ago. they say, recommit the bill, do nothing. they say, go back and start from scratch again. that's basically what they say. if you listen closely. if you listen to the music as well as the words, if you read between the lines, they say, kill it. that's what they're saying.

i hate to say it because i tend to be a pretty nonpartisan kind of guy, they're not true. sometimes you just got to call a spade a spade. that's exactly what's happening here. i might say that, you know, the medpac, the outfit that advises us, nonpart son, decides what to do here, they say that medicare advantage plans are overpaid by 14%. a typical couple that pays -- a typical couple will pay $90 more per year for part-b premiums to pay for medicare advantage even if they're not enrolled in the plans. that's not right. i might say this: medicare home health providers --er chart. one small part of that is medicare home health providers. they have an average margin of 17%. 17% for health. that's a little high. if we're trying to protect medicare benefits, we've got to make sure we're not overpaying

the medicare providers. it's just common sense. it is not the right thing toured. so many seniors need -- it's not the right thing to do. soament seniordo. so many seniors need help. you know, we have an obligation. this is a government program. we have an obligation to our taxpayers to make sure we're not overpaying hospitals, providers. we've got to do right by them and make sure they're doing ofnlgt we're just not overpaying them. that's a tough thrien draw sometimes. it is a -- its that' that's a te to draw sometimes. there's lots of grad and waste in the medicare program. the last figure i saw was about $60 billion, fraud in medicare. providers are just ripping frankly off taxpayers and seniors. we have added additional

provisions in here to outlaw that fraud, additional screening, additional certification, just different ways to make sure that medicare does a better job -- h.h.s. -- or c.m.s. does a better job deciding which providers are right and which are not right. what's the real impact of the medicare policies here? let's be clear. the real impact of these policies, even with the medicare changes in the bill, overall provider at the same times will still -- provider payments will still go up. i want to make it clear that we're not cutting benefits, folks. we are reducing the rate of growth of spending for health care providers, as hospitals and nursing homes. but reducing it in a moderate way that we're not reducing it by too much. as this chart shows, those providers still get at least a 5% net increase in payments over the years, and the groups

themselves have not really complained about them. let's take the pharmaceutical companies, hospitals, nursing homes, home health, hospice -- they're not crying big crocodile tears. remember that famous meeting down at the white house not too long ago? the industry all came in and talked to the president. remember what they pledged, all these providers, and how much they could cut the reimbursement to them. it is included to insurance companies. insurance companies, hospitals, everybody. $2 trillion over ten years they said they'd cut. $2 trillion. $2 trillion. this doesn't come close to -- or this legislation doesn't come close to cutting $2 trillion. doesn't come close to cutting $2 trillion. i think the figure is about $400 billion. that's not $2 trillion. that's $400 billion. so we're not hurting them that much.

we're not hurting them frankly. they're doing okay. i've got quotes from the hospital associations. here's sister carol keyan, president of the catholic health association. "clearly catholic health thinks the possibility that hospitals might find hospitals to be very, very unfounded." i've heard the legislation that this legislation is going to -- i've heard the climb that this legislation is going to -- he have a had so many quotes here. people believe this is okay. they're not going to pull out. "hospitals will always stand by senior citizens." the president of the federation of the american hospitals. we also know, as i said, some providers will do really well under this reform legislation. wall streetagessists have suggested that many providers including hospitals will be -- quote -- "net winners." hospitals will be net winners, according to generally the basic feeling among wall street analysts. because under our bill they estimate that hospital profitability will increase with

reform because more and more hospital patients have private health insurance. so nobody is going to pull out. there are not cuts in medicare benefits. it is true there is a reduction in some of the private plan nonguaranteed benefits that plans -- that companies would give to seniors at the expense of private-paid seniors. that is triewvment but medpac said it should be -- that is true. but medpac has said it has been cut more. we're giving them a break by not cutting them by what medpac says they should be cut back. the reductions in this bill are the providers, not beneficiaries. they're far less than the health care industry said it could save over the next decade, a reminder they pledged to save $2 trillion. right now -- over ten years. in this legislation, they're just going to be hit for $400

billion. i mentioned before the other side has often said that this is exactly what we have to do, although today they say no, no, no. they're not exactly quite sure what the difference is. years ago they said, this is what we should do. perhaps they can explain that. i might mention here, too. this is very, very important in this legislation. we happen to lose sight of the delivery system reform. one of the reasons why there's so much waste in our health care system -- and there is a lot of waste. the estimates ritz estimates a. seniors, are not given the gifts they should receive. private patients aren't getting the benefits they receive because of all the waste. the waste is basically because of the way we pay for health care in our country. we pay on the basis of quantity.

we pay on the basis of volume. we do not pay on the basis of quality, or to state it differently, a hospital -- and they probably do the right thing, hospitals -- or doctors, they try to do the right thing. they're paid on how many procedures they provide basically, not outcomes, not quality. and that's the basic route in my judgment that's causing a lot of waste in the american system. health care is provided for differently in different parts of the country. the fancy term is called geographic disparity. health care is practiced in one way in one comunts. health care is practiced another way in another community. they're very different. many of us have read that new yorker article -- the june 1 "new yorker" article written by a doctor comparing el paso, texas, with mcallen, texas. i see the two senators on the

floor here. perhaps they can help us understand what's going on in el paso and in mcallen. health care in el paso is about half what it is in mcallen, another border town. about half. people are spending -- spending for a person in el paso, texas, is about half of what it is in mcallen, texas. yet the outcome -- that is, how well patients do -- is a little bit better in el paso than it is in mcallen. why? according to the article -- the author of the article -- it is because of how medicine is practiced, what's the ethic, what's the sense in el paso regarding health care and what st's in m mca-- and what is it in mcallen regarding health care. according to the author, his conclusion is that, well, in el pass so, it's because -- in el paso, the care is more patient-centered, it is coordinated care. it is less on making a buck.

whereas in mcallen, it is less coordinated care, more specialties hospitals, a little bit more providers than trying to make a buck. the medicine is practiced so differently all over the country, geographic disparities. some states in the northern high plains states, less spending per person. outcome is terrific. some of the sunbelt states, don't want to step on the toes of my colleagues, more spending the outcome is worse. just because it is based on volume and quantity, not based on. this legislation starts to put in place twice move toward reimbursing based on quality. not volume. and that paradoxically is going to result in lower costs and higher quality. lower costs but higher quality. virtually all folks in the health care

community -- doctors, hospitals, administrators i've talked to, doctors i've talked to, health care doctors i've talked to -- virtually all say, i'll be very conservative, 80% agree, 85% agree this is the direction we have to go. this legislation goes in that direction. failure to pass this legislati legislation, which the other side wants -- that is, not to pass it -- means we don't do any of that. means we don't start putting in plays ways to more properly reimburse doctors and hospitals and other health care providers. this bill includes those patient-centered reforms i just mentioned. what are they? they include accountable care organizations, bundling is another concept, reducing unnecessary hospital readmissions, create innovation centers. this bill starts to do that. there's something else this bill

does which i know some on the other side get all exercised over and i think it's -- they get exercised over it improper improperly -- and that's ways to start to compare the -- one drug versus another, compare one procedure versus another, you know, the one medical device versus another. and we just have to start doing more of that with a nongovernment agency, with a private-public agency that works together so it gets -- gives good, solid information, so we have more evidence-based medicine in america. rye now, a lot of docs, they want to do the right thing but what they do depends upon the drug republicadrug rep that comr office and start peddling certain drugs. docs feel unease he about that, they don't like it but -- uneasy about that, they don't like it

but they see so many patients, they're busy and they're trying to keep up to date. so we're trying to keep up to date with evidence-based medicine, and with i.t., medical text nolg so they catechnology t access to the best evidence here. there's so many reasons why this legislation is so important. and i personally believe we have to move a bit toward what's called integrated systems. you know, we hear a lot about geisinger, mayo, cleveland clinic, intermountain health care, there's home health out in seattle where doctors and hospitals and nursing homes and pharmacistpharmacists are more d together and that, therefore, cuts down on costs, increases quality, is more patient-centered, it's care-crrtd, and thi -- care-coo, and this legislation helps us move in that direction. you know, we're just trying to get started here with this legislation, get started on doing some of the right things that we know we should do. we're not -- we don't have all

the answers here. nobody has all the answers. but if we get this legislation passed in the next couple three or four or five years, we work with the basic underpings of this legislation -- underpinnings of this legislation, we're going to create some mistakes, we're going to see some new opportunities, we're going to be working on getting health care costs down, which we have to begin doing to help our people, help our companies. we're going to work to get more coverage so more people have health insurance. i mean, it's an embarrassment today, it's an absolutely embarrassment in the united states of america, an industrialized country doesn't provide health health insurance for its people. i mean, it's more than an embarrassment, it's a travesty, it's a tragedy. it's just wrong. it's morally wrong. so this legislation just gets us on the right track at moving. it helps medicare beneficiaries, not hurt them, as the other side would like you to believe. it does not unnecessarily harm doctors an and hospitals. they plan to go along with it. they know it's the right thing to do.

they're still getting big increases in payments. and i just -- and there are other forums here which i haven't got time to mention tonight, but i just strongly urge us to, you know, say, hey, this is the right thing to do. let's get started. let's pass this legislation and -- and certainly trounce this -- this recommittal motion to stop what we're doing. it's not right to stop this. we're getting started here. let's keep going. i yield the floor. mrs. hutchison: mr. president? the presiding officer: the senator from texas. mrs. hutchison: mr. president, i want to talk about health care legislation. that's what we have been talking about now on the senate floor for the last week, and i expect we'll be talking about it for quite a long time. we just -- we've just begun really considering this bill, and the american people are growing in our opposition. according to a new gallup poll

released yesterday, americans now oppose this bill by an 18-point margin, 53 against it, 37 for. the report states, this gallup poll states that despite the considerable efforts of congress and the president to pass health insurance reform, the public remains reluctant to endorse that goal. but this poll is just confirming what we've really known for months and that is that the bill before us and the one that passed the house before that is the wrong approach. we are not against reform of health care. we need reform of health care. people are concerned about the rise in premiums in health care. so we ought to be looking at ways to address that issue by doing what? by cutting the costs in the system and by allowing people to have more affordable health care options, none of which is in this bill.

americans do not support half a trillion dollars in medicare cuts, they do not support half a trillion dollars in new taxes, they do not support mandates, they do not support our growing national debt, which has hit its ceiling at $12 trillion, and they certainly don't support a government takeover of our health care system. let's talk about the medicare cuts. the americans that are most indicated are those that we're usually trying to protect, our seniors. i hear others on the floor saying that there are no cuts to medicare. i'm looking at the language in the bill, i'm looking at the description of the bill, and the fact is that there are 135 -- $135 billion in cuts to hospitals, $120 billion in cuts to medicare advantage,

$15 billion in cuts to nursing homes, $8 billion in cuts to hospice. that is nearly half a trillion dollars in medicare cuts. that's $500 billion. in texas, more than half a million seniors are enrolled in medicare advantage. we know this bill will reduce their choices and the benefits that they have toda today, benes like eyeglasses, hearing aids, dental benefits, flu shots, home care, medical equipment, and more. so more and more seniors are not going to take the medicare advantage option which they now take and enjoy. this is not a solid approach. now, i have heard others on the form, on the other side of the aisle say that it was republicans who attempted to cut

medicare in previous years. the republican effort to cut medicare growth was $10 billion over five years. not up with democrat voted for a $10 billion cut over five years. and yet today they are touting a $500 billion cut over ten years. $10 billion was out of the question. $500 billion is now something that can be accepted? mr. president, there is no reason to cut medicare half a trillion dollars. we should make it last longer and be more stabilized. but, mr. president, $500 billion in cuts is just going to make it worse. it is going to make it insupportable. and the health care for our seniors will surely suffer on

its face. now, it's a fair question to say: well, what are republicans for? are you for health care reform? well, of course we're for health care reform. every one of us pays health insurance premiums and we know people who are complaining about the rise in premium costs, especially small business peop people. and we sympathize with that, we all do. so what is our approach? step-by-step reform. what the american people are looking for is reform that doesn't cripple the health care industry in our country, that doesn't bankrupt our country and that doesn't include a government takeover of the health care system. there are commonsense fiscally responsible reforms that republicans have been promoting for years and would support today if we could have a bill

that would have any republican input whatsoever, which this one does not. allowing small businesses to pull together and purchasing insurance. now, sitting on the floor with us today is senator mike enzi. senator enzi was the chairman previously of the health committee. he produced a bill. he produced a bill that would have given more people coverage than the bill before us today. allowing small businesses to come together and pool their risk pool, make it larger, and give much more affordable premiums to more small businesses so that they could afford to do what every small business wants to do and that is offer health care coverage to their employeesment but the democrats killed senator enzi's bill. that would have been the first step to health care reform and we could have passed that years

ago and been on the right track, increasing the number of people who have affordable options for health care. number two, reducing frivolous lawsuits. where states have taken the measure to reduce frivolous lawsuits like texas and a few other states, it has been a phenomenal success. it has brought down the cost the medical malpractice premiums of doctors, it has increased the number of doctors who are willing to practice medicine again, it has increased the number of doctors who will go into rural areas that are underserved. it works. the estimates are that if we had a part of this bill that would reduce frivolous lawsuits, that it would save $54 billion a year. if we could reduce $54 billion

out of the cost in the system that is not going for anything productive, we could then put that into helping either shore up medicare or give the medicare reimbursements to doctors and health care providers, to hospitals. we could help the system by cutting those costs. that is something that republicans would support in a heartbeat. how about tax incentives to people who are buying their own health care insurance? just tax credits to a family of $5,000 that would give them the ability to put that on a health care policy for their families would cut the cost and allow them to have an affordable option. and a tax deduction above the line or a tax credit would be a

huge incentive to employers as well as individuals who would be able to have that kind of help in covering the cost of health care. we're willing to support that.. allowing individuals to purchase insurance across state lines. tear down that bureaucracy that keeps people from crossing state lines and getting the very best deal for themselves and their family. even an exchange could work. that is something that is embedded in this bill but it's an exchange that has so many machine dates that it's going raise the -- so many mandates that it's going to raise the cost to everyone. just a simple exchange that has competition and transparency could actually make a difference in cutting the costs of health care. so i think there are many things that we could do to reform if we could have republican input and a bipartisan bill that would offer more affordable health care coverage to more people in our country. these are ideas that would