>> maureen with gannett. she isn't convinced yet that the bill would in fact be the deficit neutral and reduce the deficit and he wants to make sure that we'll be sure before he votes are. it sounds like you are saying he should be sure right now, that there shouldn't be anything added to this bill that would make sure that it happens. >> again, i think the bill as it stands needs those four conditions, and again, as i said, has embodies the most significant cost and came and delivered system reforms of any bill that has ever been considered on the floor of the senate. that having been said, as i already, as i also noted, more can be done and as you know there are a group of moderate senators that are considering a amendment that would amp up some of the changes especially in the delivery system reform component of those four pillars. . .

>> i think what i will do given the sensitivities of ongoing senate discussions is note there are a lot of those discussions going on and lots of discussion business opt-outs, opt-ins, triggers and leave it at that given that the bill is on the floor and there are many sensitive discussions that are ongoing. >> all right. let's stay in the back and go to the next hand over. it look it's julie.

>> i'm from npr and i'm one of five people in this room who are members of the original bras to breakfast. i think our first guest was pete starr. the congressional budget office and joint task suggested that premiums would not as the insurance industry suggested skyrocket under the senate bill but it also suggested that for most people there wouldn't be very much of an impact on premiums. now the president when he was running promised a $2500 a year decrease in premiums. how is this going to sell and do you agree or disagree with the cbo joint tax assessment of what premiums would do and this, i guess, would be in 2016 under this bill. >> well, there's a few things to note first as you know having read that document for those going into the exchange and are subsidized who are the majority of the folks who will go into the exchange there are dramatic reductions in excess of 50%. i'd also note that -- remember

the analysis was done for 2016. it, therefore, does not reflect all of the -- nor in some sense should it because these things take time -- does not reflect all of the changes that we have been discussing with regard to delivery systems and reforms and those four pillars and what have you. the whole theory of the case here is that the current system is unsustainable. and that you are putting in place an infrastructure so that we can make better decisions in the future and help to move towards quality and lower costs. and i think that's exactly what the legislation is doing. >> all right. let's just come a row forward. you had your hand up right in the center there. >> i'm from cch. you seem to be endorsing whole handedly the senate revenue provision as far as taxing high end health insurance. does that in effect basically write off the house approach?

>> i don't know that i explicitly endorsed anything. i think what i said is that these economists have put out the four key pillars and i think the administration supports the thrust of those four key pillars which is we are in favor of a fiscally responsible health reform and again, i think we've got a vision here of what that means. >> move over to mort there. >> i'm from roll call. i don't expect you to tell us what's going to be in your budget in february but everybody -- but all the anticipation is that you're going to finally tackle the long-term deficit. now, everybody has said that the key to tackling the long-term deficit is to bring entitlements under control. yet, the entitlement reforms vis-a-vis medicare are in this bill to pay for the healthcare system. so are you going to include more

medicare reductions in the budget in order to bring things under control or is medicare not going to be part of the long-term deficit fix? second question, the president made a stirring appeal last night for bipartisanship. the question is, can you or can you tell me what's wrong with the two main republican ideas, one, medical malpractice reform that really sticks and secondly, the ability of people to buy insurance policies across state lines. >> sure, let me deal with that second one first. and actually you know rather than going into a critique, let me just point something out on that and turn to your other question. the folks who say the bills are not doing enough or the savings are not adequate or what have you typically point to cbo scoring and say, the savings are not sufficient or cbo is not able to -- nor should it project

forward five or six decades and say this is what's going to transform the healthcare system. and then when pressed, what specifically would you do to make that situation better, the answers are the two things that you mentioned. being able to purchase insurance across state lines and medical malpractice. so if you hold people to the -- you know, a consistency standard and say, well, what does cbo say about those things? the answer is cbo says both of those things would have very, very modest effects on costs and quality. so just for -- for the sake of sort of intellectual consistency, if you're going to point to cbo and say the bills don't do enough even though cbo suggested that they are deficit-reducing, and then put up those two proposals as the key missing ingredients, you should be willing to live by cbo's analysis of those two provisions and again, they're not overwhelming.

i'd also point out as you know the house has a national exchange whereas the senate has a state-based exchange system. in a world in which you had a national exchange as under the house bill, the ability to purchase insurance across state lines is -- becomes effectively moot. so under the house bill, it's not even really particularly relevant. with regard to your first question, obviously, we'll have more to say about what will be in the budget when we put out the budget. but i would want -- i want to highlight that with regard to moving towards a continuous improvement system so getting in place an innovation center, more comparative effectiveness research, a medicare commission, it strikes me that it would not be practical -- i'm not -- i'm not licensed to practice politics, and you know more about that than i do. it strikes me that it would not

be practical to get those kinds of provisions into just an entitlement reform bill. and it will be a remarkable accomplishment if we succeed in passing this legislation again because it puts in place a structure that allows future entitlement decisions to be oriented towards quality and efficiency in a way that doesn't really exist today. so we'll have a lot more to say in february. i will note that fiscally responsible health reform is necessary but not sufficient to address our medium-term deficit and long-term deficit problem and there is more than that will be necessary and we'll be talking more about that in february. >> let's take a question here in the front from cheryl. >> hi, cheryl stoleberg from the "new york times" i would like to ask an average joe question.

you talked about laying the foundation for a system that will be more efficient and pay we'll have more quantity and not quality. over what time freezing raenvise have in this country a health system that is efficient and works properly? >> well, i think it's not -- there's not a sort of demarcation point where we declare mission accomplished. it is a gradual process that, you know -- that will be moving forward. [inaudible] >> it will be years to decades to -- but just continuous forward. your doctor in too many cases today does not have any basis -- doesn't have the evidence to know whether this approach or that approach is better. and we need to be reducing the

number of situations in which that's the case. >> so can we narrow down years or decades? >> no, the point is -- >> 30 million added to the system that's already more than five years away but some time beginning five years from now -- >> well, no, i think it will even begin before that. i mean, remember, we have the health i.t. funding and we have the comparative effectiveness research and that will be occurring much sooner than 2015. but this is -- this is not -- i think this is the key thing. this is not one of these -- improving the quality of healthcare, it's more like a life-long nutrition or diet, not studying for an exam. you don't just, you know, study for the exam and you're done with it. it requires continuous effort and what we're doing in this legislation is putting in place a system that will make that easier to do and more -- and in a more auspicious approach than

what we have now. but just like with, you know, a lifelong effort, it's not like you're done at any point. it will require continuous -- continuous effort and, therefore, it's not -- the reason i'm not giving you a specific answer is, it's just something you have to keep working at. >> spoken like a true middle aged person. >> there we go. >> in the rear, please. >> rich with fox business. >> hi. >> you've talked a lot about the excise tax. it's been weakened a bit in the senate version from what the finance committee had originally come up with. there's some talk about perhaps a different index, maybe to weaken it further. are you comfortable with the level at which that tax sits now or can there be further modifications to it or should it be made stronger? >> i think -- most of the discussion about changes -- well, because it was the main

thing that was changed between the senate finance bill and the floor involved the starting threshold. and what's key from a cost containment perspective is the rate at which that threshold is increasing over time. and that was not changed. and the reason that that's key is what you're doing with regard to how rapidly that threshold is rising is that you're creating an incentive for plans, for employers, to design their plans in such a way that they're under that threshold. and since the threshold is rising less rapidly than healthcare costs, you're creating an incentive -- or healthcare costs without reform, you're creating an incentive to slow the growth rate in private health costs. cbo, for example, suggested that with regard to the people whose plans would be in that zone, you could get a 9 to 12% reduction in premiums by 2016.

the result of that is that you shift compensation from health benefit into take-home pay and that's why most of the revenue that is coming from this provision actually comes because plans -- companies are able to make their plans more efficient. as a result, take-home pay goes up. and as a result, there's some associated revenue with that. [inaudible] >> what i said was from a cost containment perspective the indexing, the rate at which it's increasing over time is more important than where you start. >> just to follow up quickly, peter, why is it possible that the risk will simply be that individuals end up bearing more of their healthcare costs than employers simply increase co-pays or cost-sharing so that in effect the health expenditures are maintained. it's just that we end up bearing more of them as individuals? >> well, i think there are a couple responses. one is most of the evidence suggests or not most basically

all the evidence suggests that with a very generous health insurance plan relative to a more, you know, efficient moderate -- a very high cost plan as opposed to a more moderate cost plan than utilization rates are much higher than that higher cost plan so it's not just that you're sloshing money. it's easy to slosh money around and it's easy to shift money from an employer to an employee. what the evidence suggests is what would happen is the aggregate amount expended on healthcare declines. and that means that the increase in take-home pay in your cash wages is more than sufficient to compensate for any additional healthcare costs shifting and you wind up with more available cash. >> okay. a question back in the rear, please. >> hi, anna with congress daily. there have been some the members, especially, some of those who are still kind of uncomfortable with the bill or

want to make some changes who want the administration to say exactly where they stand on some of those differences, public option, employer mandate, do you expect there'll come a time and when, when the administration will do that and if not? why not? >> well, the administration has laid out some -- you know, has laid out our views on a whole variety of questions. there have been lots of people who have raised questions about, i suppose, the legislative strategy. but i would point out again, we are -- i mean, it's worth pausing. we are further along in getting comprehensive health reform than we have ever been before. and i'd also note -- i probably should have said this. from a cost containment perspective, if a year ago, november or december of last year, someone told you that a bill would be actively debated on the floor of the united states senate, that expanded coverage by more than 30 million, reduced the deficit, had a medicare commission in it and had an excise tax on high

cost insurance plans contained in it, i think most of you would have been -- to say you would would have been skeptical would have been -- would have been an understatement. so people can always complain or question, but judging by results, we are further along and under the leadership of the folks who are running the legislative strategy piece of this, further along than has ever been the case before. >> i'd move over to the other side of the room. let's take a question in the front, please. >> hi, joyce friedan from internal medicine news. the bill puts a lot of emphasis on comparative effectiveness research and getting the most cost-effective treatment for things. and i'm wondering if the uproar over the mammogram and pap smear guidelines has given you any concern about whether people will be able to put in to effect changes that will mean fewer

treatment or procedures? >> no. look, i think the goal of the comparative effectiveness or patient-centered health research is to make sure that your doctor has more information in the future than now on what will work. and the big problem that i see -- there are a lot of cases where the evidence is ambiguous and folks can debate. and i would include the recent discussion in that category. the more important problem from my perspective is there's lots of areas and too much healthcare spending where we simply have no evidence, whatsoever, about whether what's being done is beneficial especially relative to an alternative. and that's where we should be focusing our attention. building out -- let me put it this way. if the problem were that we had evidence on all of the things that were being done and there was that category of ambiguity across the whole array of healthcare spending, that would be a high class problem to have at this point.

that's not the main problem that we have. the main problem that we have is that there are lots of things being done where it's not clear what the benefits are and there's no evidence, whatsoever, either pro or con that has been -- that has been developed. and that's what we need to be doing. >> we'll stay on that side of the room for a moment and take a question right -- in the next row right behind. >> lauren montgomery with the "washington post." hi, peter. >> hi. >> so just as the house rejected the excise tax, if i'm not mistaken they've also rejected the medicare commission. how critical is it that the final bill that has leadership be persuaded to adopt an independent medicare commission? >> well, i don't know i would use the word "rejected" as opposed to not included in their bill. [laughter] >> look, i don't want to get into, you know -- there's a bill on the floor of the senate. the next stage after the senate passes the bill as you know it it will be a conference in

between the house and the senate and let's let it play out. >> there are a number of proponents of the commission who think that the version even in the senate legislation has been greatly defanged. if you look at the language it's not clear what the commission would be allowed to actually do or recommend. and some of the things it's been restricted from taking on like hospital payments would suggest it isn't going to have very much leverage. why would we consider that a really firm pillar of the reform at this point given how much it has allegedly been defanged? >> well, i'd say two things. first for those who argue that none of these things matter, there sure is a lot of effort going into to try to alter or change the provisions. so there's a little tension between saying none of this stuff is for real and then we're going to put a lot of effort in weakening or changing or what have you. i think the key thing at this point is the medicare commission exists. as i said, there are things as we move forward that will need

to be tweaked and modified. and i know that there is significant discussion ongoing about whether the medicare commission -- the provisions of the medicare commission could be modified as the process moves forward. >> okay. we'll stay again on this side of the room and pick up a couple more questions here and then we'll come back over here. right there. >> hi. i'm with the "l.a. times." there have been some discussion last year perhaps unrealistic that controlling healthcare spending, a key to that would be trying to use money within the healthcare system to offset the costs of paying for a coverage expansion. but it seems, in fact, that the legislation has been going in the opposite direction in some sense. the addition of a medicare payroll tax for high incomed earners. even the cadillac tax is dependent in some sense on the income tax to offset the cost. how concerned are you that given that dynamic that, in essence,

we're just pumping more money from outside the healthcare system into the healthcare system going forward and that will only exacerbate the problems of excessive spending? >> well, actually i'd say again taking -- since the one that's being debated right now, if you take the senate bill, the vast majority of what's happening is that you're taking resources that are already committed to healthcare and redirecting them towards, you know, in various ways. the vast bulk of the savings that are used to finance coverage, more than finance because you have net deficit reduction, more than finance the coverage expansion come from within the healthcare system not only reducing some of the inefficiencies and other things in medicare and medicaid but i would include the excise tax as coming from a commitment of the federal government. basically, it reflects a tax

expenditure that is currently devoted to healthcare and it's curtailing that tax expenditure. >> okay. we'll come back over here. take a question right here in the center. >> hi. doug with american medical news. you spoke a lot in the past about the dartmouth conclusions and how there's potentially 30% of health spending was not effective or was inefficient. i'm wondering over the past few months there's been a scaling back from the dartmouth folks. i'm wondering do you believe that number is a workable estimate or is there some other smaller figure that you think is more realistic? >> well, first i'm not aware that dartmouth even elliott fisher have scaled back the number at all. there was just worth pointing out -- there was a medpac report that came out yesterday that examined the variation in spending and then the variation in utilization patterns.

that is, once you adjust for different wage rates and health conditions of the population. and what it definitively suggested is that although once you control differences in wage rates and health conditions across regions and across parts of the united states, the variation is less. so in other words part of the explanation is that external factors vary. there's very substantial variation that persisted. that's consistent with evidence that when i was the director of the congressional budget office we examined suggesting this huge variation in spending across the united states for reasons that are not correlated with outcomes. and that the various explanatory -- the variables that you could use to try to explain it might reduce the variation by say a third or a half leaving a huge amount of variation that is not explainable and that is not correlated with outcomes.

and, in fact, if anything the higher spending regions seem -- this is worth pausing. we have very significant variation across regions in the united states, across hospitals within a region and even across doctors within a hospital. and the kicker is that whenever you drill down into any of those levels, the variation of across regions and hospitals and across doctors and try to examine whether for a given type of patient the folks who are doing more spending get better outcomes, the answer is almost universally no. there is a very limited number of exceptions to that general conclusion. and in general if anything the conclusion tends to go the other way. [inaudible] >> my understanding is that -- and again, i'd refer you to the dartmouth folks. i'd point out it's not the dartmouth folks who come up with numbers that are in that range. but also the mckinsey study of cross-country comparisons and

frankly the institute of medicine workshop that has examined the potential for efficiency improvements in healthcare. they all are centered around figures in that range. >> i think there may be a conflation of numbers here, too. the 30% refers to the estimates of the medicine that is of no value. not the variation. the variation is not necessarily 30% -- it's maybe 30% in some is areas with respect to medicare. but it's going to be different if you take into account other data. so i think it's two different sets of numbers there. a question right here. >> hi, susan with reuters. the economy is still struggling and the healthcare sector repeatedly points out how they are one area where growth is a good thing. there's a number of jobs. there's innovation. so how do you -- how do you tackle that? how do you reduce healthcare spending and the costs curve and unnecessary care? how do you factor that against this industry where jobs and the

economy is obviously still a huge concern for people? >> well, don't forget, i think whatr we need to do is the sectr needs to be experiencing the same sorts of improvements that are common in other sectors so that you are orienting again towards outcomes rather than just doing more. in no other sector do you have this -- well, in very few other sectors do you have such strong incentives just for volume. and that is not the right incentive to be giving any market. you want to be providing an incentive for quality, not quantity. and so i don't think this really speaks to the question of the sectors financial health or employment levels but rather what those people are doing. we need to be getting more from the dollars that we're investing in healthcare. >> we'll take a question right here from chuck.

>> chuck babbington with a.p. now that there's a bill on the senate floor, i'm wondering what your thinking is about the path to get final passage. you know very well what certain senators have said, lieberman, landrieu, lincoln. ben nelson. if you take them at their word several of them are not going to vote with a bill with a public option and yet many democrats in both houses are adamant about a house option. what path do you see? >> you know i think i'm going to let senator reid -- my job is hard enough. i'm going to let senator reid do his. he is, as you know, managing the -- managing the movement in the senate and he is confident that he's going to get to where he needs to be and i'm going to let him manage that process. >> i appreciate that. but at the same time, you've been -- you and others have made trips up there including this week. can you give me any sense of sort of what your -- >> no. [laughter]

>> good try, though, chuck. john? >> john with "congressional quarterly" health beat. a pretty key piece of the financing for the healthcare legislation is medicare cuts to hospitals. and rick pollack of the american hospital association said earlier this week that the coverage levels are not high enough yet to merit cuts of the magnitude that have been proposed. he's talking about a 97% standard of coverage. my question is whether, you know, is that feasible from your point of view financially and if so, how does that get paid for? >> well, look, the legislation does include a very significant expansion in coverage. it's not surprising that various provider groups would prefer to have more people covered and less cost containment. i mean, that's not shocking. but if you look at any of the analysis that has been put forward from medpac or frankly

from cbo, what your accomplishing in this legislation is a very significant expansion of coverage without creating significant problems with regard to access either with regard to hospitals or doctors. so i think i'll just leave it at that. it's not surprising that providers will always want less constraint on their reimbursement rates and more people in their business flow. [inaudible] >> okay. we'll take -- let's take one more question over here and then we'll come back and pick up on final. >> christina with talking points memo. i'm actually curious about former senator tom daschle and former senator ken salazar now secretary of the interior and why the administration is sending them to the hill. if you have -- obviously, you can't talk about what they're saying in these private meetings but why are they doing these negotiations right now?

>> well, i think, look, getting a comprehensive health reform bill done is challenging. it's very worthwhile but it's challenging. and we are doing the things that senator reid believes will be helpful in his effort to get the bill passed. >> all right. let's take a final question. >> we'll leave this event now as the u.s. senate begins day 3 of debate on its healthcare legislation. $848 billion plan to expand health insurance to most insurance. -- americans. barbara mcculsky has one that is likely to get a vote today. it eliminates copayments for many preventive healthcare services for women. live senate coverage now on c-span2. senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. eternal god, thank you for the

gift of this day. help us to use it for your glory. guide our lawmakers to labor with diligence for the good of our nation. deliver them from bitterness, frustration, and futility, as they lift their eyes to you, their ever-present help for life's difficulties. lord, save them from the futile repetition of old errors and the restoration of old evils. may they live such exemplary lives that people who see their good works will glorify you. use the members of this body to

increase opportunities for more abundant life to people everywhere. help our lawmakers to be aware of your nearness and to recognize your voice as you lead them to your desired designation. we pray in your sacred name. amen. the presiding officer: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all.

the presiding officer: the clerk will read a communication to the senate. the clerk: washington d.c., december 2, 2009. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable tom udall , a senator from the state of new mexico, to perform the duties of the chair. signed: robert c. byrd, presidet pro tempore. mr. reid: mr. president? the presiding officer: the majority leader is recognized. mr. reid: following leader remarks the senate will resume consideration of the health care reform legislation. it will be for debate only until 11:30, alternating blocks of time. the first 30 minutes will be under the control of the republicans. the majority will control the next 30 minutes. the senate will recess from 11:30 until 12:30 today. following the recess the senate will resume consideration of the health care legislation. hopefully we can have some votes this afternoon.

we've been unable to work that out with the majority, and we'll see what the afternoon brings. this historic health reform bill before us is strong, and it's a strong, strong head start in the right direction toward urgently needed change. like nearly every bill that comes before the senate, it stands to benefit from the constructive input of all senators. this good bill will be even better after this body debates it, refines it and improves it. we're pleased we've begun the amendment process. i hope we'll soon be able to begin voting on these amendments once drafted and sponsored by democrats and republicans. as we give the detailed parts of this bill, let's not forget the big picture. so, as the third day of debate on this bill, let's remember what it does. first, we're making it more

affordable for every american to live a healthy life. second, we're doing it in a way that's fiscally responsible, in a way that will help our economy recover. this bill does not add a dime to the deficit. quite the opposite. in fact, we cut it by $130 billion in the first ten years and as much as three-quarters of $1 trillion in the next ten years. we do this by keeping costs down. this critical piece of legislation will cost less than $85 billion a year over the next decade, well under president obama's goal. it will make sure every american can afford quality health care. we'll make sure that more than 30 million americans who don't have health care today will soon have it. we'll not only protect medicare, we'll make it stronger. in short, mr. president, this legislation saves lives, saves money and saves medicare. the congressional budget office and respected economists outside washington have studied it and they agree. the bill will set out what we

set out to do at the beginning of this congress. it will lower costs and increase value so all americans can afford quality health care, not just a few. experts have crunched the numbers and come back with positive reviews. it will help parents afford to take care of their children, it creates more choices and more competition in the health care market. it will protect everyone begins the insurance companies abuses. for all the changes in the system where the health care system does work, keeps it the way it is. i'm really happy with the way democratic senators have stood up for these principles and those who have defended them against all attacks from the other side. one after another republicans have come to the floor with disingenuous claims. for example, they talked about health care premiums, overlooking the fact those costs will go down for the vast majority of americans. in fact, 93%.

they've talked about the deficit, ignoring the fact that health reform will do more to lower the deficit than any other measure in years. in -- remember, over 20 years, almost three-quarter of a trillion dollars. they tried to scare seniors saying you're going to die sooner as an example, closing their eyes to the fact that we strengthened medicare, cut waste, fraud, and abuse from the program. they certainly have tried to scare women, closing their ears to the fact that we'll make it easier than ever for women to get the preventive screening they need, and that's a gross understatement. they claim to speak for the american people, but neglect to mention for the last year what americans have consistently said more than ever, they want their health care system back to health. what is the most consistent tact of the republicans in this bill. they carefully count the number of pages in this legislation but

employeesly discount the number of people it helps. can anyone think of a more superficial way to measure the worth of a bill than how many pages it's printed on? as far as i can tell, the only threat that poses is more paper cuts, perhaps. those who want to keep the broken system the way it is, throw everything they can at the wall but nothing has stuck. and incredibly, my distinguished counterpart, the republican leader, last week called the health care crisis manufactured in spite of the fact, mr. president, that 750,000 people filed for bankruptcy last year, 7% of them because of health care costs. in one sense, my republican counterpart is right. it was manufactured. this health care crisis has been manufactured by the greedy insurance companies who raise families rates on a whim and deny health care to the sick. mr. president, remember the health care industry is exempt from the antitrust clause.

they can conspire to fix prices with no civil or criminal penalties. no other business is like that except baseball. this crisis has been manufactured by leaders who enable them, who empower them and who sit idly by while the problem grows worse and worse and finally collapsed into a crisis. republican friends have been so busy coming up with distortions that they forget to come up with solutions. they seem more concerned with scaring the american people than helping them. this barrage of baseless accusations stresses they have no vision for fixing a health care system that is broken. yes, correcting the record has taken a long time. that's okay, we'll continue to do so as long as necessary. democrats are more than willing to defend this good bill. after all, it's not hard to do. as mark twain, a great nevadan,

said, "if you tell the truth, you don't have to remember anything." so, mr. president, i appreciate, especially do i appreciate my friend, the assistant leader, my friend of decades, senator durbin, for his brilliant statements on the floor during the last several weeks on this health care issue. i so admire his spunk, his intelligence and his ability to deliver a message. the presiding officer: under the previous order, the leadership time is reserved. under the previous order, the senate will resumption of h.r. 3590, which the clerk will report. the clerk: calendar number 175, h.r. 3590, an act to amend the internal revenue code of 1986 to modify the firsttime home buyers credit in the case of members of the armed forces

and certain other federal employees, and for other purposes. the presiding officer: under the previous order, the time until 11:30 will be equally divided with alternating blocks of time, with republicans controlling the first 30 minutes and the majority controlling the second 30 minutes.

mr. enzi: mr. president? the presiding officer: the senator from wyoming is recognized. mr. enzi: i'd suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

quorum call: mr. kyl: mr. president? the presiding officer: the senator from arizona is recognized. mr. kyl: i ask unanimous consent that further proceedings of the quorum call be dispensed with. the presiding officer: without objection, so ordered. mr. kyl: thank you, mr. president.

to continue our debate on the mccain amendment to ensure that medicare benefits for our seniors are not cut, as would happen under this legislation, i wanted to talk a little bit about the commitments that we've made to our seniors and what would happen exactly under the legislation that is before us. as we all know, seniors have paid into the medicaid program and that's with the expectation that they'll get the benefits that have been promised to them. so the question is, why would we at this point reduce the benefits that have been promised to them, especially if the purpose is not to enhangs the financial viability -- enhance the financial viability of medicare, which everybody knows is going broke, but, rather, to use that money to establish a new entitlement program? let me just break down the list of cuts that seniors would face under this legislation. $137.5 billion would be cut from

hospitals that treat seniors; $120 billion from the medicare advantage plan, and, by the way that medicare advantage plan serves almost 40% of the arizona seniors on medicare; it cuts $14.6 billion from nursing homes; $42.1 billion from home health care; $7.7 billion from hospice care. these are deep cuts and you can't avoid jeopardizing the health care that seniors now have under medicare by making these deep cuts. and that's why the chief actuary at the centers for medical -- excuse me, medicare and medicaid services -- we use the initials c.m.s. -- believe this would cause some providers to end their participation in medicare, which of course would further threaten seniors' access to care. there wouldn't be as many providers to whom they could go for their services. now, our friends on the other

side of the aisle say that part of this is an intention to eliminate waste, fraud, and abuse. and, of course, we've known for many years that there is waste, fraud, and abuse in medicare, but actually doing something about the problem and recognizing it are two different things. if it were easy to wring hundreds of billions of dollars of savings from medicare by just pointing to waste, fraud, and abuse, we would have done it a long time ago. certainly the president would, during his first year of office, want to do that given the fact that we're spending a lot of money and he's trying to find sources of revenue for the various spending programs that he's proposed. so if it were that easy to do, it would have been done before now. moreover, medicare faces a $38 trillion 75-year -- whatever savings could be

achieved, you should do that to make medicare solvent. now, the next thing i want to talk about here is what seniors are telling us. they believe, according to public opinion surveys -- and i know i've talked to enough of them to know that this is true -- that they believe that these medicare cuts are going to jeopardize their health care, and they're troubled, in particular, by this $120 billion proposed cut to medicare advantage. it's been called the crown jewel of medicare, and it's the private insurance addition to medicare in which many are able to participate in programs that they wouldn't ever be able to afford otherwise. it gives them this choice to supplement the traditional medicare to provide all kinds of benefits, such as dental, vision, hearing, and physical fitness programs and other things, as i said, that they couldn't get otherwise. one in four of the beneficiaries in arizona, as i said, sign up

for this program, more than 329,000 seniors. they like the low deductibles and co-payments in medicare advantage, but the congressional budget office has bad news for the seniors who like this program and who like the extra benefits that they have under medicare advantage because, as the congressional budget office notes, it would cut benefits, on average, by 64% over the next ten years from an actuarial value of $135 to $49 a month. now, think about that. the actuarial value of the benefits that the average medicare advantage participant has is worth $135 a month today. it would be cut in this bill to $49 a month. that's a 64% cut, according to the congressional budget office. so when we say that we're not cutting benefits that seniors currently receive, that's not true. this legislation would do that.

i've been sharing letters from constituents who have expressed concerns to me about this. let me just share three more letters today. one arrived recently from joseph and marylou dopak of sun city west, in arizona of course. "the plan to reduce our coverage and take $120 billion from medicare advantage is a slap in the face to all seniors. medicare advantage works because medicare funds are given to a private insurance company to administer the plan. we do not want our medicare advantage plan robbed to fund a government-operated comprehensive health care plan. common sense tells us that will not work. the president should be fixing what ails the current health care system instead putting everybody into government-operated health plan. it is totally unfair to put this on the shoulders of those upon

whom this country has been built." another letter, "i'm a senior citizen, age 83. if i lose my medicare advantage coverage, i'll also lose my primary care physician of 18 years because he does not accept medicare direct. senator kyl, do not let nem take away my med -- do not let them take away my medicare advantage." mr. president, i get these letters every day. i haven't had a constituent come up to me yet and say, please, would you take away the medicare advantage program. it is not right. everybody that has talked to me, of course, has said, please, preserve this important program. a senior that suffers from multiple sclerosis describes what it means to her. "i am a 57-year-old woman with multiple sclerosis currently on social security disability. i make under $14,000 a year and have been on the secure horizon medicare advantage program for a while now. we need to keep our medicare advantage plans in order to have

quality health care at a price we can afford. we need you to help protect medicare advantage plans for the seniors in your state. we are the ones you need to fight for. and we shouldn't have to choose tbeen going to a doctor and getting our medication and having food on the table and a place to live. please do your part to protect our medicare advantage plans and keep prices within our reach." mr. president, as i said, these are the kinds of letters we get all the time. and it's hard for these folks to understand, first of all, why, having paid into the plan and having taken advantage of what is a good supplement to the basic medicare, that that would be taken away from them. and i think it's even harder for them to fathom that the reason it's being done is to pay for a new program rather than to keep medicare itself solvent. well, i tell folks like this that i will continue to fight for her. i'll continue to try to protect this program because we believe it's essential. and it's why i support the

mccain amendment to commit the bill back to committee. it only has to be there a day. we're not talking about a further delay here. but it addresses both of the key issues of cuts and savings. if the mccain amendment passes, it would send the bill back to the finance committee with instructions to remove the medicare cuts from the bill. that's all it does. but secondly, those savings would be applied to medicare rather than to fund a new government program. those savings could, therefore, address the waste, fraud, and abuse problem that has been identified by everyone. it could be used to strengthen the medicare trust fund, rather than to fund a new health care entitlement program. so we believe that the first thing we should do to see whether or not we can actually fix this bill -- and i've been quoted as saying that i don't think we can fix this bill. and with that, i mean, i don't think my colleagues would not

want to make the changes necessary for the american people to be able to support this kind of legislation. seniors are overwellcomingly opposed to the -- are overwhelmingly opposed to the medicare cuts. if my colleagues on the other side of the aisle aren't willing to support the mccain amendment or something like it, i don't know how we can then say that we can fix this bill. so i hope my completion will use this process -- so i hope my colleagues will use this process to make amendments to the bill and not simply have a political discussion. republicans have pointed out that there are better ways to reform the health care problems that we have today than to do it on the back of seniors. we've put forward a bounty of ideas. let me just recoup some of them. we think that we could start and we could save a great deal of money by medical malpractice reform. that would bring down costs. we could allow americans to buy lower-cost insurance policies across state lines. that alone would unleash a wave

of competition for patients' business. we could allow small businesses to ban together to get the same purchasing power that big businesses have. but these ideas have essentially been ignored by the majority. instead, we have this big government takeover of health care rat a huge cost and significant -- at a huge cost and significant reduction in quality and benefits to people. we don't think this is the way to go and certainly on behalf of my senior citizen constituents and others who are on medicare programs, i'm going to continue to fight for them, as my colleague john mccain is, and, therefore, urge my colleagues to support his amendment to eliminate the medicare cuts under this bill. mr. brownback: mr. president? the presiding officer: the senator from kansas is recognized. mr. brownback: mr. president, i rise to speak in favor of the mccain amendment and just do it from a perspective of a representative of the state of kansas. we have a number of senior citizens and hospitals that are medicare-dependent hospitals. we have a number of providers that a majority of their practice is medicare

reimbursement. and they're scared to death of these cuts, and the cuts are well-documented and known. $500 billion in medicare cuts towards -- and for the 43 million senior citizens on a program that's already projected to go insolvent by 2017. specific cuts of $135 billion from hospitals, $120 billion from 11 million seniors? medicare advantage, nearly $15 billion from nursing homes, nearly $40 billion from home health agencies, and then a cruel gesture, it seems to me, nearly $8 billion from hospices, where people are getting their final care from cancer and diseases that are killing them. $8 billion cut cuts from hospic. what that does in a state like mine and in many rural hospitals that we have is it cuts the legs out from under them. they aren't going to have the money that they need to operate.

now, they're going to do everything they can to continue to operate, and they'll probably -- what they will try to do is to tax their local citizenry, raise property taxes, in all probability to make up for the medicare cuts because they're going to have a hospital there and they're going to do everything they can to keep the hospital there. but what a terrible gesture on our part here to take money that's been going into medicare and people have been paying into medicare and then to steal it for a new program that's not going to get everybody covered on top of that, and from a program that's already set to go insolvent by 2017. so it's like writing a big fat check on an overdrawn bank account that is to start something new, to buy a new motorcycle. you're going, that doesn't make sense to people. then it seems cruel and unusual to the senior citizens that you're taking $500 billion and

really gut ago lot of their care programs, and a program that doesn't work. i met earlier within the last several days with the kansas association of anesthesiologists. they're saying this is really going to hurt us and our ability to provide services and care. i've talked with other individuals that look at this and they say, now, wait a minute. you're going to change everything to try to get a few more people covered, and you're going to gut a medicare program that's not paying the bills now, that a number of private-pay insurance plans are helping to subsidize medicare and medicaid, and you're going to cut the reimbursements that aren't making things work yet. it makes no sense to individuals. -- that this would take place. i get caught by a number of individuals across the state of kansas saying that they are very scared of this bill and what it's going to do to their health

care. i do telephone town hall meetings, as a number of individuals across this body do. and the individuals there that you get on a random phone call-in basis are scared and mad about this bill and the prospects for what it does for their health care. i get it from individuals, i get it from mail. i was in a meeting in kansas the week of thanksgiving, polled the audience. it was an audience that was mostly over the age of 65. how many were in favor of the overall bill? there were about 200-some people. ten were in favor. how many are opposed? everybody else with a few saying they don't have an opinion. but it was 90%, 95% opposed to this bill. and it's because they look at it, and they see what it's going to do to them, and they don't see it providing the care that is being promised. and adding on top of all that to the deficit. one of two things is going to happen on these medicare cuts,

because we've seen in the past efforts to control the spending in medicare passed by this body, and then each year those efforts to try to restrain the spending in medicare being restored. so one of two things is going to happen. either these cuts in medicare are going to take place, and it's going to cripple the program and particularly hurt it in a number of rural areas across this country and in my state, or these cuts will never take place in medicare, and it's going to add to a ballooning deficit and debt that's taking place right now. either choice is an irresponsible choice for this body to do. it's irresponsible for us to do to this country. most people look at it and say i want to get more people covered and i want to bend down the cost curve, but let's do that on an incremental basis. senator kyl spoke ahead of me about incremental changes that can take place whether it's tort reform, allowing bigger pooling

on health reform, starting community-based clinics, something that worked in my state to get more people covered in an earlier phase in their health care needs. all of those are incremental, low-cost, and in some cases ones that actually do bend down the cost curve that can really help and not a tkpwar gargantuan $2.5 trillion that takes $500 billion out of medicare that's already headed towards insolvency in less than a decked. the bill doesn't make sense to individuals. and then to do it on top of a time period when the president ten days ago comes back from china meeting with our bankers, as most people look at it, and the bankers lecturing us on "why are you spending more money which you don't have, going further and further in debt, which you shouldn't do at this point in time," being lectured by the chinese when we ought to be talking to them about what they're doing on human rights and what they're doing with their currency, we're being

lectured on fiscal irresponsibility and it is because of bills like this, bills like this. if we'd stop and slow down and listen to the seniors across this country, i think there is a commonsense middle ground that we can go to that doesn't cost anything along the nature of this, doesn't change most health care for most people, but addresses the narrow problem of getting the cost curve down, of getting more people covered. this bill with these cuts in medicare cripple many of my providers in the state of kansas and make them raise property taxes to keep the hospital open, to try to provide doctors in the community, or a lot of the hospitals are going to go closed and a lot of the providers are going to stop providing medicare. or in all probability these cuts will never happen and it's going to be added to the debt and deficit, completely irresponsible towards our kids. i'd urge our colleagues to vote for the mccain amendment that makes sense, that is what the

citizenry of this country wants to do and send these cuts to be pulled from medicare out of this bill. thank you, mr. president. i yield the floor. a senator: mr. president? the presiding officer: the senator from tennessee is recognized. mr. corker: mr. president, how much time is left on our stphaoeud. the presiding officer: 7 minutes and 6 seconds. mr. corker: mr. president, i thank you for allowing me to speak this morning. i'm glad to be on the floor with the distinguished senator from kansas, connecticut and montana. we have obviously before us one of the most important issues that we will deal with in this body. mr. president, i've had over 40 town hall-like meetings since the beginning of august, and i can say without hesitation their never used those meetings to try to focus on some of the hot-button issues that divide us in this country. on not one occasion have i tried to do that.

i tried to focus on the fundamentals of this health care bill. and, mr. president, way back when, when i began meeting with the distinguished chairman of the finance committee, which i greatly appreciated his desire to meet with me and realized that medicare may be a place where money will be taken to leverage a new entitlement, i began expressing my concerns about that. later i sent a letter to majority leader reid, signed by 36 senators, talking about the fact if medicare moneys were used to leverage a new entitlement, we could not support that effort. mr. president, the reason i say this is that this is the same exact thing i have been saying about this bill from day one, before it was ever constructed. and so i'm very dismayed that we find ourselves here in december debating a bill that does exactly that. when i first came to this body, there was a lot of concern in this body about the solvency of

medicare. i think everyone here knows that the trustees have talked about the fact, have stated that in 2017 medicare will be absolutely insolvent. two senators from opposite sides of the aisle have tried to create legislation that would put in place a commission -- eight republicans, eight democrats -- to actually solve that issue because we realize that we do not have the resources in medicare to actually deal with the liabilities that we have with seniors all across this country. so, mr. president, the fact that we are taking $464 billion in savings out of medicare to leverage a new entitlement, to me, is totally irresponsible. the same thing i've been saying from day one, i'm dismayed that we in this body would consider kicking the can down the road, making sure that people of the generation of the many people that are helping us here on the floor today will be straddled

with huge amounts of cost down the road that they will not be able to deal within a very responsible manner. so, mr. president, i am very discouraged. the fact is that the other piece of this that is extremely troubling is that we all know we have the issue of s.d.r., the doc fix, which is a colloquial term to describe the tpabt that -- the fact that in a year citizens across this -- physicians will be receiving a 23% cut for serving medicare recipients. it means that recipients will have less physicians to deal with the needs they're going to have at that time. this bill, instead of dealing with that issue, deals with it for one year, mr. president. and what that means is there's about $250 billion worth of expenses that are not being dealt with with this medicare savings. so let me walk through it one more time. we have a program that is

insolvent. we have a program that cannot meet the needs of those people who have paid into this program for years and that many of us continue to pay into. this program is insolvent, and we're going to take moneys out of this program $$464 billion -- something that most americans cannot do, something that does not pass the commonsense test in tennessee. and my guess is doesn't pass the commonsense test in most states around this country. we're going to take $464 billion out of this program, this entitlement, which is underfunded and insolvent, and we're going to leverage it to create a new entitlement for americans across this country. and yet, we're not going to deal with the issue of the docs fix, which is a $250 billion issue. we're going to kick the can down the road. we're going to cause physicians around this country next year to, if this bill passes -- if

not, certainly they're going to be dealing with that this year. but we're going to cause physicians around this country another year to be concerned about these huge cuts, not deal with it in this bill, and possibly end up with a $250 billion obligation that could have been dealt with during this health care reform that now is not met, that is going to create additional fiscal burdens to this country and certainly great distress to seniors and physicians who care for seniors. so, mr. president, again, i've tried to -- i have tried to stick with the basic fundamental building blocks of this bill. i don't think anybody in this body has ever heard me focus on some of the more emotional issues. the fact that we would use medicare moneys to create a new entitlement, the fact that we would have an unfunded mandate

to states through medicaid of $25 billion, to me, is problematic. the fact that premiums are actually going to increase, whether it's a c.b.o. number of 10% to 13% or the oliver wyman number in my state which says 60%, the fact that private premiums are going to go up. and fifthly, the fact that we're using six years' worth of cost and ten years' worth of revenues. mr. president, i don't know how we've gotten caught newspaper this debate in such a manner that we are ignoring basic fundamentals that i don't think any of us, any of us on our own accord would consider supporting. the fact is that i'm afraid that this, again, has become nothing but seen as a political victory for the president. mr. president, what i hope we will do is step back and do some

things in a bipartisan way that will stand the test of time. i ran on health care reform. i'd like to see us do responsible health care reform. the basic fundamentals of this bill do not meet that test. mr. president, i see that my time has expired. i thank you for the courtesy. i thank the senators on the other side of the aisle that have worked hard to put this bill together. i hope that they will step back away from these flawed fundamentals, and i hope that in some form or fashion we'll put together a bill that will stand the test of time. thank you, mr. president. the presiding officer: the senator from connecticut is recognized. mr. dodd: mr. president, let me just take a few minutes, if i will. how much time do we have now? the presiding officer: 29 -- 30 minutes. mr. dodd: mr. president, let me, first of all, talk about, if

i can, the medicare issue because this has been the subject of sort of round and round debate back and forth over the last couple of days. i think it's important that, just to share with you again as emphatically as we know how what's being done mere with regard to medicare. the whole idea is to strengthen medicare, to put it on a sounder footing, to extend it solvency to eight years from five years, making it a sounder source of medicare that older americans need. the organization representing older americans, which doesn't lightly endorse proposals without examining them thoroughly, hardly a partisan group given the fact of where they have been over these years, in the last 24 hours has put out once again a statement from them laying out the facts of what is included in the bill drafted by the finance committee, principally in this area -- medicare. let me just recite, if i can,

the facts as they identify them. fact number one, they say, none of the health care reform proposals being considered by congress would cut medicare benefits or increase your out-of-pocket costs for medicare services. that's not from the democratic national committee. it's not from the "help" committee or the finance committee. this is from aarp, saying here, "none of the proposals in this bill cut medicare benefits or cut medicare services. fact number two, the health care reform bill drafted by the finance committee will lower prescription drug costs for people in the kphaeurbd coverage gap, or the so -- in the medicare part-d coverage gap. again, this is not from some partisan group announcing what's in the bill. this is from the objective nonpartisan analysis of the bill that is before us. fact number three, health care reform will protect seniors

access to their doctors, reduce the cost of preventive services so patients stay healthier. again, that's critical. let me just point out to our colleagues and again others, i presume, understand this, it's almost -- it's so axiomatic, you wonder why you have to explain it. if you can catch a problem before it becomes a major problem, that is through mammograms, colonoscopies and other things, obviously through screenings, and discover that an individual has a problem and caught early enough can address it. many of my colleagues know because it became rather public, i went through cancer surgery in august because it was discovered i had an elevated p.s.a. test indicating i had prostate cancer. that screening let me know that i had a growing problem that i had to deal with. so i went through a variety of discussions. what's the best i should do? what's the best way to handle

all of this? and decided that surgery made the most sense. the cost of that surgery -- the cost of that surgery is expensive. it's not cheap early on, $5,000, $6,000, $7,000, 8,000 to do it. if i had not skoefrd i had prostate cancer and become one of the men to die or had to deal with that i am told it could have easily cost $250,000. i was not only allowed to stay alive and stay healthier with two young daughters looking forward to the day to dance at their weddings, but also the savings because it didn't grow into a problem with a massive expenditure to deal with it. our bill deals with that. we provide for the first time ever that seniors and other americans have access to prevent screening, or prevention of screening tests to allow them to discover the problems they have early on.

that is according to to aarp. that is what we draft in this legislation. that is major, major benefit. our colleague from north carolina yesterday talked about nurses in a hospital in her state of north that are that were not getting the mammograms early not because they didn't want them but because the kwroufl pocket expenses -- the out-of-pocket expenses are so high that they couldn't afford to do it, pay rent, put food on the table and take care of their families. that hospital in north carolina decided they would no longer require their nurses to pay those high out-of-pocket skpwepbss and elimb -- expenses and eliminated that. as a result, almost every nurse in that hospital got mammograms early on and could identify problems before they became larger issues for them to grapple with. that's a major, major achievement, a major achievement. the suggestion here that we ought to roll back and recommit this bill and eliminate the kind of savings we're talking about

here in order to make the kind of investments so people get screenings and have the early prevention tests to eliminate the fear that you may discover one day you have a problem that no longer can be streeted with a low-cost kind of -- treated with a low-cost kind of treatment, that's going to require massive expenditures of chemotherapy or other things that cost a lot of money that put you at great risk of surviving with those kinds of problems. as a united states senator, i have a health care plan that provides that. we all get to do that. why should the united state -- a united states senator's prostate be more important than anybody else? why shouldn't others be able to get that screening to determine whether they have prostate cancer in that'? that's what we're talking about in this bill. to say we're going to throw the bill back into committee again,

we all know that wha that means? it means that we're going to put an end to that legislation. thmr. president, i say respectfully to our colleagues, having been through this at great length over the summer, filling in for our friend, who we've now lost, senator kennedy, we went through long debates and discussions early on, a lot of discussion, bipartisan discussions. as i pointed out earlier, the bill that cyme out o came out o" committee conducted the longest markup in the history of that committee. in that ways, that bill is a bipartisan bill. it didn't get bipartisan votes, unfortunately, coming out of committee. but the substance of the legislation includes the ideas and thoughts of our colleagues across the political specter and it is important that the public

know that during this debate. this is not a bill that was rushed through, jammed through. my colleague from montana, senator baucus, spent weeks and weeks and weeks -- months -- and i attended many of them, of his meetings, in his office where democrats and republicans gathered around the table late into the evening talking about how we could shape this bill on a bipartisan basis. no one can accuse the senator fr of montana of not reaching out to the other side to be a part of this solution. he went beyond the extra mile to achieve that. he was flatly turned down, regretfully in that effort. but that shouldn't be an effort that we don't try to move forward. i'm still hopeful that we can get bipartisan support for this bill before it's concluded. we're working at it on the floor of the united states senate in this debate. it is an opportunity to come forward and make constructive suggestions, not recommitting the bill, because you can't get a scoring on what you're suggesting, so send the bill back to committee -- i in effec,

kill the legislation. that's what would happen if the mccain were adopted. i want to share what nonpartisan outside groups, not this kind of debate where the democrats say medicaid gets cuts, the republicans say, no, it doesn't. listen to what these groups who are reviewing every sill in this bill to determine what it does to people and the most important ukes significant organization that represents the interests of the elderly in this country have analyzes this bill and have said to america, this is a good bill. this bill strengthens medicare, provides benefits, reduces costs. and that's what we've tried to do over these many, many months. so let's move on. if you want to change all of this let's offer an amendment and move forward ands. i urge my colleagues to reject the mccain amendment because i think his proposal would do

great damage. with that, mr. president, i would yield the floor. the presiding officer: the senator from montana is recognized. mr. baucus: mr. president, i noted that the other side the last couple two, three days has tried to make the case that seniors' medicare benefits are in jeopardy because -- quote -- "this legislation cuts medicar medicare." i've heard that statement over and over and over and over again. in fact, the last speaker on the other side made that same point. i'm co confounded. i'm very surprised when i hear those statements. why am i very surprised in because it's totally, patently false. it's false. it's untrue. there are no benefits cuts here,

none. one could say that the private plans, the medicare advantage plans, which are vastly overpaid -- the nonpartisan medpac organization states that they're vastly overpaid by 18% -- one can say those private plans -- it is not medicare -- those private plans, medicare advantage -- those aren't medicare plans, those are private plans, private insurance plans -- they may be overprescribed some nonguarantee the benefits for beneficiaries, something like eyeglasses or things like that. that may be cut back; that is true. but none of the basic benefits under medicare that every senior knows about when they go to during the and gets care under med compare is reduced. nothing is cut. in fact, this legislation adds d benefits to seniors.

it virtually fills up this thing we call a doughnut hole; that that's the portion of -- that is, that's the portion o the seniors have to pay. that's filled. that's additional benefit. then all this screening -- the screening provisions that are in this. there are many, many other benefits that are added on to the ordinary benefits that seniors have. so it is not true -- it is not true -- that the basic guaranteed benefits under medicare are cut. none of the guaranteed benefits under medicare are cut, none. none. so it's totally untrue. it's false when people make the claim that -- quote -- "medicare is being cut." now, they're being very, very clever, the people that make those claims. what they're saying when they say medicare will not be cut,

they want you to think that they mean benefits will be cut. but what they're -- deep in their mind they're holding back in their mind, they're saying, well, when pressed -- well, it's the medicare providers. the a the hospitals -- it's the hospitals, it's the medical equipment manufacturers, the pharmaceutical industry. that's being cut. that's medicare. that's being cut. and, therefore, that'll hurt seniors. and that's kind of the way they get around it. well, mr. president, the fact is that the way you preserve the solvency of the trust fund is to make sure that there aren't so many payments, frankly, by uncle sam going to pay for all the doctors and hospitals and so forth, so the solvency of the trust fund is extended. and right now this legislation extends the solvency of the medicare trust fund. if this legislation were not to

pass, the medicare trust fund would probably go insolvent about the year 2017. but this legislation extends the insolvency of the trust fund about five more years to 2022. and so i just want to make it very clear that this legislation that we're considering today does not cut medicare benefits. in fact, the hospitals and doctors are going to find at least a 5% increase in growth over the next ten years in payments to them under the medicare program -- growth. i've had a chart -- i showed it yesterday on the floor that showed for each of the various years. it is a 5% increase in growth for all of those dispris. -- it is a 5% crs increase in growth for all of those industries. you ask analysts on wall street how hospitals are doing, they're

doing great under this legislation. you ask analysts on wall street how the pharmaceutical industry is doing, they're doing great under this legislation. you ask any analyst about the other industries, home health care, hospice care, you name it, they're all doing okay. wall street analysts say they're doing fine. they're not -- and why are they doing fine? why objectively are they doing fine? and why do the c.e.o.'s of these organizations not grumble too much? because they know that what they may lose, a little bit of a reduction in their payments, they're still going to get big, hefty payments, they'll make up on volume because so many more people have health insurance. they know that. they're going to make a lot of money. so they're okay. so it's not true that medicare is going to go broke under this legislation. first of all, there's no reduction in benefits. that's very clear. that's very clear. senator dodd read a letter from aarp making that very clear. and also the reductions are not

really reductions in provider payments; they're reductions in the rate of growth of provider payments. and they're going to do fine. the providers don't care that much because they're making it up on volume because srve going to have health insurance. they have quite a bit -- they have a 5% growth rate anyway. so it is not true -- it is not true -- that medicare is going to -- is in jeopardy. the president's legislation. it is not true that the benefits are going to be cut. in fact, just the opposite is true. this legislation strengthens benefits, increases benefits, extends the length of the medicare trust fund to a future date farther down the road so it stays solvent longer than otherwise is the case. this legislation helps seniors, it helps seniors, contrary to what you hear on the other side that it hurts. if you look at the facts, not

the rhetoric, not the rhetoric. look at facts, look at what the supporters of this legislation and the objective groups say about this legislation, you cannot help but be compelled to the conclusion that this legislation is not only goods for seniors, it is very good for -- is not only good for seniors, it is very good for seniors. mr. mcconnell: mr. president, with apologies to my good friend from montana and connecticut, i was unavoidably detained at the opening. and i would now like to give my opening remarks. the presiding officer: the senator has the floor. mr. mcconnell: the challenges of the ongoing war in afghanistan are immense, but americans believe in the mission, and they trust the advice of our commanders in the field to see that mission through, so i support the president's decision to follow the advice of general petraeus and general mcchrystal in

ordering the same kind of surge in afghanistan that helped turn the tide in iraq. these additional forces will support a counterinsurgency strategy that will enable us to begin the difficult work of reversing the momentum of the taliban and keeping it from power. the president is right to follow the advice of the generals in increasing troops. and he is also right in increasing the ability of the afghan security forces so they can protect the people. by doing both, he's made it possible for our forces to create the right conditions for afghanistan, the right conditions for them to defend themselves, create a responsible government, and remain an ally in the war on terror. although our forces are in afghanistan to defend our security interests, the people of afghanistan must assume a greater burden in the future. the president's plan recognizes that.

once we achieve our objectives oon an afghanistan that can defend itself, defend its borders, and remain an ally on the war on trashings then we can discuss a withdrawal, a withdrawal based on conditions, not ar temporary time lines. but for now we owe it to the american people-to-, to those who died on 9/11 and to the many brave americans who have already died on distant battlefields this this long and difficult struggle to make sure that afghanistan never again serves as a sanctuary for al qaeda. ant to the men and women who are now deployed or who will soon be deployed to provide every resource they need to prevail. now, mr. president, on one other subject, with every passing day,

mr. president, the american people become more and more perplexed about the democratic plan for health care, and they like it less and less. americans thought reform meant lowering costs. this bill actually raises costs. americans thought reform meant helping the economy. this bill actually makes it worse. americans thought reform meant strengthening medicare. this bill raids it to create a new government program that will have the same problems that medicare does. americans wanted reform. what they're getting is the opposite. more spending, more debt, more burdens on families and businesses already struggling just to get by. one of the biggest sources of money to pay for this experiment is medicare. this bill cuts medicare advantage by $120 billion. it cuts hospitals by $135

billion. it cuts home health care by $42 billion. it cuts nursing homes by $15 billion. and it cuts hospice by $8 billion. reform shouldn't come at the expense of seniors. and the mccain amendment guarantees that it wouldn't. the mccain amendment would send this bill back to the finance committee with instructions to remove the language that cuts medicare. the mccain amendment also says that any funds generated from rooting out waste, fraud and abuse should be used to strengthen medicare, not to create an entirely new government program. a vote in favor of the mccain amendment is a vote to protect medicare. let me say that again, mr. president. a vote in favor of the mccain amendment is a vote to protect

medicare. a vote against the mccain amendment is a vote to raid this vital program in order to create another one for an entirely new group of americans. so a vote against the mccain amendment is a vote to take money out of medicare to create a program for an entirely different set of americans. a vote against the mccain amendment is a vote against our seniors and it's a vote against real health care reform. mr. president, i yield the floor. mr. dodd: how much time remains? the presiding officer: 13 1/2 minutes. mr. dodd: let me yield myself 5 minutes if i may, mr. president.

i just want to come back if i can. do you have those charts with you? i want to put up these charts. again, i say this respectfully because i genuinely believe people across the spectrum here would like to see some reform of the health care system. the question is whether or not the proposal that has been laid before us here by the finance committee and the "help" committee achieves reform and whether or not the ideas we bring to the table are actually going to achieve lower costs, greater access, improve the quality of health care. we believe very firmly and strongly that it does, and outside observers of this process who have no political agenda whatsoever but really make a determination as to whether or not the goals that we have sought in this legislation achieve the desired results are there or not. it is the conclusion of the major organizations that make these determinations that in fact we have done exactly what we set out to do. but i want to point out because i think it's important, what i

wh*e i hear the arguments from our friends on the other side about their deep concerns about medicare, it's very, very important that they understand that over the last number of years we've seen quite the opposite reaction when it comes to the medicare program in our nation. going back, if you will, to 1995, when our friends took over the control of this body and the other body and began a process. the then-speaker of the house newt gingrich announce the to the world that he was prepared to let medicare -- and i quote him -- wither on the vine. that is not 1965 when the program was adopted. that is merely 15 years ago, 14 years ago when the other party became the dominant party in congress. one of the first statements from the leader of that party was to let that program wither on the vine. again, that's one person, the speaker, the leader of the

revolution that produced the votes electorally in 1994. i think it is a backdrop when we hear the debate about medicare, it is important to have some history on where the parties have been on this issue generally speaking. in 1995 we begin with that as a backdrop. in 1997, two years later, it happened again. in 1997, here were the proposals. in 1997 medicare's funding as proposed in the republican balanced budget act of that year were twice of what we're talking about in the savings of this bill. a 12.4% reduction in medicare benefits in 1997. and of course in the last budget submitted by president bush last year -- and i think, again, it's reflective of where things were at. this is a year ago, not 14 years ago or not 1997. in 2009, the bush administration in submission of its budget proposed a $481 billion reduction in medicare benefits. that was not in the context of a

health care reform bill. that was just in the context of a budget proposal. here we're talking about savings by reducing costs in hospitals and other providers as a way of strengthening medicare, providing more benefits to the beneficiaries themselves and things like prescription drugs as well as in screenings and early prevention efforts which are included in our bill which have been identified, of course, by aarp and the commission to preserve and protect social security and medicare and they have analyzed our proposals and suggested we do that. our bill saves $380 billion in order to strengthen the medicare proposal. it improves the quality of health care for seniors as part of our comprehensive reform. stph-fbgt, senator coburn -- in fact, senator coburn's patient choice act proposals more cuts in medicare advantage than our bill does. i find it somewhat intriguing for those who are arguing for

the coburn proposal as an alternative and yet simultaneously suggest we ought not to do anything to medicare advantage have not read the coburn bill. because he cuts $40 billion more out of medicare advantage than what we do in our legislation as proposed. in conclusion from the national committee to preserve social security and medicare, again, not a partisan organization -- their sole mission is to see to it that social security and medicare will be there for the people who it is intended to support. in a letter sent toefry united states senator yesterday to the commission, let me quote exactly from them, "not a single penny of the savings in the senate bill -- the bill now before us, mr. president -- will come out of the pockets of beneficiaries in the traditional medicare program. the medicare savings included in the house bill, the patient protection affordable care act, will positively impact millions of medicare beneficiaries by slowing the rate of increase in

out-of-pocket costs, improving benefits, and it will extend the solvency of the medicare trust fund by five years. to us, this is a win-win for seniors and the medicare program." end of quote. we could hear all the partisan debate back and forth as to what this bill does. but if you're interested in what those organizations whose sole mission is to analyze whether or not beneficiaries are going to be advantaged or disadvantaged by what's being proposed here, they categorically unequivocally suggest that the mccain amendment would do just the opposite of what our bill does. it would roll the clock back, damage seniors terrible by reducing or eliminating the provisions we've included in our bill. and they strongly support what the finance committee wrote in its bill that is now presented to all of us here as a way to strengthen and sperpbg the medicare program -- and preserve the medicare program. i say to my colleagues and the others, you can listen to this partisan debate back and forth as to whether or not you want to

believe the democrats or believe the republicans. i would suggest if you're not clear who to believe in this, listen to the organizations whose skwrop it is to -- whose job it is to protect this program, with whom we have worked very closely to determine we would not in any way reduce those guaranteed benefits senator baucus addressed in his remarks. that is why this is a good bill and deserving of our support. i urge our colleagues to reject the mccain amendment. mr. president, i yield the floor. the presiding officer: the senator from montana. mr. baucus: mr. president, the republican leader just a few moments ago says that this bill raises costs. with all due respect to my good friend from kentucky, that statement is false. just this week the nonpartisan congressional budget office, the organization that analyzes legislation, both sides, both

bodies depend on it -- a very professional outfit, i might add -- said that our bill would reduce premiums, not increase, but reduce premiums for 93% of americans. and for all americans, it would make sure that better quality insurance is available. let me state that a little bit differently. the congressional budget office said that for 93% of americans, premiums would be reduced. it is true that for 7% that's not the case. those are americans whose incomes are too high to qualify for subsidies. that is, the tax credits, buying insurance in the exchange. but those 7% would get a lot better insurance, a lot higher-quality insurance than they get today because of the insurance market reforms that are in this legislation, the

provisions which deny insurance companies from denying coverage based on preexisting condition, health status, the market rating provisions, no rescissions, et cetera. so for all americans, it is true that this legislation will provide better-quality insurance comparing apples with apples. 93% reduction for all americans. the other percent for whom there is not a reduction, those people would have a lot higher quality insurance. add to the fact the quality would be much higher, it would be succeed the increase in -- it would exceed the increase in premiums. this is looking at it to the year 2016. they didn't look at it for other years. at least that is the case for 2016. reduction, not an increase. reduction.

in fact, for many in the nongroup market -- those individuals who buy insurance -- they find their premiums will be reduced about 40% or 50%. about 60% of those in the nongroup market are finding their insurance premiums will be reduced. i don't have the exact figure in front of me, but it's in the neighborhood of 40% or 50% reduction in premiums. that's due to tax credits. again, c.b.o. says that those tax credits would cover nearly two-thirds premiums. i guess that is a little conservative. it would cover two-thirds of premiums. c.b.o. says that those getting these tax credits would pay roughly 56% to 59% lower premiums than they would without our bill. and those are real savings, mr. president. that's with respect to premiums. what about out-of-pocket costs? this legislation has absolute

limits on out-of-pocket costs. today insurance companies can give you -- sell you a policy. you pay certain premiums. if there is no limit on the out-of-pocket cost you have might have to pay or deductible is so high, for example, this legislation puts an absolute limit that no policy can be sold that allows you to have out-of-pocket costs above a certain amount. i think it's $6,000 for the individual. it might be double that for a family. but there's a limit. so this bill does not, as stated by the minority leader, raise costs. in fact, the fact is it reduces costs. in addition, there are many people who say, oh, gosh, this is a $1 trillion bill. some even say it is a $2.5 trillion bill. senators on the other side of the aisle make this statement. and they say this to try to scare us. i think they kind of -- i'll be honest with you, i don't know if

they really believe it but they're saying that because it is a nice, good scare tactic. i say i'm not sure they really believe it. i wonder if they believe it, because when you read the legislation, it is deficit-neutral. it does not add to the deficit. we have a budget resolution, mr. president. under that budget resolution, the budget has to be deficit-neutral. it cannot add one thin dime. when people talk about a trillion-dollar bill, it doesn't cost anything, it reduces the deficit by $130 billion in a ten-year period. that's what the congressional budget office says, the professional nonpartisan budget office. and the second ten years the c.b.o. says our bill reduces the deficit by a quarter of a percent of g.d.p. well, that's roughly $500 billion. the second ten years, this bill

reduces the deficit by a half a trillion dollars. so i don't know why the people on the other side say this is a trillion-dollar bill. there's one senator on the other side -- i am not going to say his name -- this is a $2.5 trillion bill. i mean, it is not true. just not true. it's not true because it's paid for. now, i can say that something costs something, but it will be only fair if i also say that it's paid for. i think it's fair to give both sides of the story, not just one side of the story. and i'm giving both sides of the story. it does cost $1 trillion over ten years, but it is paid for. it is more than paid for. and those that say $2.5 trillion, they start at a different date. they start at a date like 2014 up through 2020. that's i didn't think so it costs so much. well, it's paid for during those years, too. so this bill is to make -- just

to make it very clear here, this bill does not raise costs. it in fact lowers costs. the congressional budget office says so. this bill does not add to our federal deficits. in fact, it reduces our federal deficits. and i would just urge us to look at the facts closely whenever we are hear statements being made by anybody, including myself. i just urge people to kind of listen to the music as well as the words, read between the lines, see what's really going on here. what my father used to say a long time ago, basically, he said, don't believe everything you read and only half of what you hear. just take everything with a few grains of salt. i think the truth starts to emerge. mr. alexander: mr. president, i agree with the senator from montana. that's why it's for the that the that we have 22 minutes on the republican side to clear up some

misconceptions. the democratic health care bill does cost $2.5 trillion over ten years when it's fully implemented. it's, if i may say so, arrogant to think that the american people couldn't figure out the difference between the first ten years when the bill wasn't implemented in four of those years and they'd like know that it costs $2.5 trillion. mr. baucus: would the senator yield for a question? mr. alexander: if it is on your side, i'll yield. mr. baucus: is it paid for? mr. alexander: the senator is right. that's the subject i would like to talk about. it is paid for by cutting grandma's medicare. it's paid for by cutting grand grandma's medicare by $465 million over a ten-year period of time, the -- mr. baucus: that's a debate -- that's a second question i'd love to debate with you, but on the first question only, you do admit that it is paid for? mr. alexander: i -- no, i admit that it costs $2.5 trillion in the attempt to pay

for it, medicare cuts and tax increases and increases to the deficit by not including the physicians reimbursement in the health care bill. mr. baucus: if i might ask one more question, i this that i we all know that the house has taken action on this position of reimbursement. the senate will also take action on it before we adjourn. that is the so-called doc fix will be fixed, which is really a separate issue. that will be paid for. but putting that aside, the doctors' issues aside, just health care reform, i say that because we take up the doc fix virtually every year. we have don't take up health care reform every year. health care reform is an entirely separate proposition, a separate legislative endeavor here. but if the senator will just bear with me and take the doc fix -- put it off the table just for a second -- week address that later -- just for a second -- health care reform, whether you use a ten-year number or when you start in 2010 or start

in 2014, wherever you start at, so it's either $1 trillion or it's $2.5 trillion, depending on where you start, without getting into how it's paid for, is it paid for, therefore it is not a deficit? am i not correct? mr. alexander: i will concede to the senator from montana that the attempt of the democrats to pay for their $2.5 trillion bill are medicare cuts, tax increases and additions to the deficit by now including the physicians reimbursement which is the essential part of any ten-year health care plan. there may be other problems, but those are the three things that i know about that -- mr. baucus: one more question on my time? mr. alexander: fine with me. mr. baucus: is it true that apart -- is it through there are no cuts in guaranteed beneficiary payments? there are no cuts, none whatsoever in this legislation of guaranteed benefits? mr. alexander: i would say no to that, mr. president, because

the director of the congressional budget office made it clear that there would be specific cuts in benefits for those who have medicare advantage, which is about one out of five seniors. mr. baucus: is it true that those provisions are not guaranteed provisions? i'm talking about guaranteed benefits that people -- that seniors expect to get when they go to the doctor, fee-for-service, expected benefits they expect to get under ordinary medicare, not benefits that a private plan, in addition, might pay. mr. alexander: well, mr. president, in response to the senator, it is clear that there are $465 million in cuts in medicare. the president, the senator from montana, the senator from connecticut, all of us have agreed that that's half of how the bill -- or a big part of how the bill is supposedly paid for. and it's specific enough to say that $135 billion comes from hospitals, $120 billion from medicare advantage, which 11

million seniors have, nearly $15 billion from nursing homes, $40 billion from home health agencies, $8 billion from wh hospices -- that's the baucus bill that came from the finance committee, and this bill is not that much different. and the director of the congressional budget office testified that provisions like that would result in the specific cuts to benefits for medicare advantage. he said that fully half of the benefits currently provided to seniors under medicare advantage would disappear, which the changes would reduce the extra benefits such as dental, vision, hearing coverage that would be made to beneficiaries. mr. baucus: one more question. does the senator agree that this legislation will extend the solvency of the medicare trust fund for five years and failure to pass this would mean insolvency of the medicare trust fund would not be extended for five years?

mr. alexander: mr. president, i would wholeheartedly disagree with that assertion. the medicare trustees have said that between 2015 and 2017 medicare will be approaching insolvency, and they ask that we take urgent action and the urgent action recommended by the democratic majority is that we take $465 billion out of the medicare program over ten years and spend it on a new entitlement. that's hard for me to understand how that can make medicare more solvent when you take money out of grand massachusetts medicare and spend if -- out of grandma's medicare and spend it on someone else. mr. mccain: to respond to another question, isn't it, shall we say, enron accounting when you have a proposal that you, as soon as the bill comes law, you begin to raise taxes and cut benefits and then you wait four years before any of the benefits are then extended

to the beneficiaries? that -- that, on its face, is a remarkable piece of legislation. my experience, which has only been 20-some years, is that we haven't passed legislation and said, we're going to collect taxes on it for four years and then we are going to give you whatever benefits that may adpriew this legislation. again, there has been no time in history, i would ask my colleague -- there's been no time in history where we have taken money from already a failing system to create a new entitlement program. mr. baucus: which colleague are you asking? mr. mccain: pardon me? mr. mccain: i believe the senator from te tennessee has te floor. mr. baucus: yes, he does. mr. mccain: then obviously i was addressing the person who has the floor, which i'm sure the senator from montana should understand by now.

mr. alexander: well, i would say to the senator from arizona that he is exactly right. or another way to describe it, the senator from kansas said it was like writing a big check on an overdrawn bank account to buy a big, new car. i mean, that -- maybe another way, if i could respond to the senator from arizona -- and i would ask consent that the republican senators and our time be allowed to engage in a colloquy. mr. baucus: might i ask the senator another question? with respect to the question from senator the senator from a- mr. alexander: i would like to respooned to the senator from arizona. i hope the parliamentarian is keeping track. i'm enjoying the questions. a great compliment has been paid to the senator from arizona. it is rare that a mere united states senator can have something he said begin to break through the fog and a

"washington post" columnist wrote a column talking about it being all about grandma and wondering why we never mention grandpa? maybe the columnist has not seen the movie "the big fat greek wedding," where the man said i am the head of the house and the woman said, i am the neck. the fact of the matter is we take $465 billion over ten years out of medicare. grandma and grandpa and those who are younger who are looking forward to medicare are going to be affected. and i wonder, if i may say to the senator from arizona -- and then i see the senator from oklahoma and nebraska here -- it wasn't long ago, in response to your question -- in fact it was 2005 -- when our democrat colleagues sought to -- when we sought to restrain the growth of medicare by $10 billion over five years.

and this is what they said. remember, they're restraining the growth of medicare by $465 million and spending it on a new program and republicans were at the time trying to save $10 billion over five years. "an immoral document," said senator reid. senator dodd, the senator from connecticut, "funding for medicare would be cut." senator rockefeller, "a moral disaster of monumental proportion." senator boxer in the same way compared it to katrina. senator kerry, "we're passing the costs on to our seniors." senator levin, "we're going to be hurt by this bill." irresponsible and cruel" said senator kohl. senator reid, senator hillary clinton -- that was to restrain the growth of medicare to spend it on the existing program. yet this proposal by the democrats would take $465 billion and spend it on a new program -- mr. mccain: and isn't it true,

now that the senator from montana is on the floor, if he wants to enter in here, maybe he could respond to his comments 14 years ago, "we weren't trying to create a new entitlement program," which is the object of the senator's bill. we were just trying to enact some savings in the medicare system. so what does senator baucus say -- and above all we must not use medicare as a piggy bank. what are we using $483 billion in cuts in medicare for? then the senator from montana said, "that is disgraceful. perhaps some changes lie ahead. but if they do, they should be made sore the single purpose of keeping -- they should be made for the single purpose of keeping medicare for senior citizens and people with disabilities." isn't it true that we are taking $483 billion out of a system that is failing, that the medicaid trustees say is going to go bankrupt? so the senator from montana 14 years ago at least said "seniors could easily be forced to give

up their doctor as doctors begin to refuse medicare patients and hospitals, especially hospitals close." isn't that the effect of taking $483 billion in cuts in medicare? then the senator from montana went on to say, "equivalent to blowing up the house and erecting a pup tent where it used to be." well, if that's blowing up the pup tent, i would say this is a hydrogen bomb. and finally, "staggering, staggering." and now of course under the senator from montana's bill, the leadership proposes something like $2k 50 billion in medicare -- something like $250 billion in medicare cuts. "it is staggering." we learn a lot over time, all of us do here. we learn about the issues. i hope that -- apparently the senator from montana didn't learn much because he was deeply concerned 14 years ago about very small savings in medicare.

now he wants to spend $2.5 trillion, taking $483 billion out of medicare to create a new entitlement system. mr. baucus: might i rye spond to the senator in -- might i respond to the senator? mr. mccain: the senator from tennessee has the floor. mr. alexander: i am happy to see a debate break out on the senate floor. mr. baucus: here is your chance. mr. alexander: as long as it is on democratic time. mr. baucus: it is both sides. even time. mr. alexander: no. whatever time you use should be on the democratic side. mr. baucus: correct. the basic question here is obviously how to protect medicare benefits. that's the basic question. i think most of us would agree, how do we protect medicare benefits and how do we extend the solvency of the medicare trust fund? i think that's the basic question. i think we'd all agree that excessive payments to providers

would cause insolvency of the trust fund to come earlier rather than later. i think we all agree with that proposition. the next question is: what would excessive payments to providers be? do providers get paid excessively? i think that is an honest question we should ask ourselves in a way to help extend the solvency of the medicare trust fund. and, in fact, in 1995, many standards, especially on your side of the aisle, did say just that, we've got to cut medicare in order to save benefits. that was made by many senators. i've got them in front of me if anybody wants to hear them. i'm not going to go through all that, but it's the truth. and that's exactly what we're doing here in this bill. we're trying to help extend the solvency of the medicare trust fund by cutting down on excessive provider payments to

medicare trust fund. how do we decide whether payments are excessive or not? that's the basic question here. and all we can do is just give it our best shot. make our best judgment. and we have to, i think it makes sense to look at the recommendations by outside independent groups, what they think. and one is medpac, the medicare advisory committee. that's an outside group, as we all know, advises congress on medicare payments. we're not, members of congress, you know, totally competent to know exactly what dollars should go to which industry group. i mean, we've got too many other obligations here to think about. but we're -- we must be responsible as senators to do the best we can. well, medpac has said these groups have been overpaid. and wall street analysts tend to agree. medpac said with respect to medicare advantage that they have been overpaid -- i've

forgotten the exact amount, but much less than the $118 billion reduction in this bill. in fact, i totaled up and looked at the growth rate, the projected growth rate of providers -- hospitals, nursing homes, home health, hospice, pharma-- tpa*r -- pharma, 6.5%, that is the growth rate of providers. we decided to trim that a little bit. we decided to trim that down to 1.5%. it is now 5%. it is a 5% growth rate for all the industries here in an attempt to try to find the right levels of reimbursement to providers with which that trim will also help extend the solvency of the medicare trust fund. and when we talk to providers, they basically agree with those cuts. they basically agree. why do they basically agree?

they basically agree because they know that with much more coverage, with many more people having health insurance, they can spread out, you know, their business. but they may lose a little on margin, they can pick up on volume. that's exactly what their business plan is under this bill. wall street analysts say -- and i quote them -- "industries are doing great. they're doing well under this bill. they're not getting hurt." we do achieve a win-win -- i don't like that phrase win-win, but i'll use it hear. the solvency of the trust fund is being extended. and reimbursement rates to providers is fair, not getting hurt. it's fair. and that's why they want this bill, by and large. most groups tend to want this bill enacted because they know it's good for the country, it's good for seniors, and it's good

for them too. mr. mccain: mr. president, could i just mention again, $70 billion with fraud, abuse and waste. and senator coburn, the doctor, can tell you, there is nowhere in this bill. the fact is maybe some of the providers have been bought off and jaw boned and had their arms twisted and given a good deal like frma has, but the recipients haven't. the medicare recipients know you can't cut $483 billion without ultimately affecting their benefits. and that's a fact. again, conspicuous by its absence, i say to the senator from montana, totally conspicuous by its absence is any meaningful malpractice reform which has been proven in the state of texas and other states to reduce costs, to increase the supply of physicians and caregivers. and there's nothing in this bill that's meaningful about medical malpractice reform. i had a town hall meeting with doctors in my state, and every one of them stood up and said i

practice defensive medicine because i fear of being sued. so if you're really serious, i say to the senator from montana, if you're really serious about this medical malpractice should be a key and integral part of it. even the c.b.o. costs it out about $54 billion a year. when you count in all the defensive medicine, it could be as much as $200 billion over ten years. that's conspicuous by its absence. i think it brings into question the dedication of really reducing health care costs across america. mr. baucus: we've enjoyed our discussion -- mr. alexander: we've enjoyed our discussion with the distinguished chairman of the finance committee and thank him for his questions. senator coburn, who is a physician, the senator from montana has talked about doctors being overpaid. he talked about -- mr. baucus: no, no, no. with all due respect, i did not say that. mr. alexander: did i hear the words providers overpaid --

mr. baucus: i talked about hospitals and others -- mr. alexander: aren't physicians providers? mr. baucus: this legislation pays more to primary care doctors, 10% increase in medicare reimbursement for each of the next five years. i did not use the word "doctors." mr. alexander: mr. president, i must have misunderstood because normally when we talk about providers, we talk about hospitals and physicians. we have a physician on the senate floor, the senator from oklahoma, and i wonder if he, having heard this debate, might want to comment. i might say, isn't it true that the mccain amendment which we have on the floor would send us back -- send this back to the finance committee and say if there are savings, let's spend it on medicare to actually strengthen? mr. coburn: i thank the senator. the first comment i would have is relying on what a wall street analyst says today. they have about this much credibility in this country today. look at the economic situation

we find ourselves in because of what wall street analysts have said. that's the first point i would make. the second point is the majority whip yesterday said we should not cut medicare -- we should cut medicare advantage because of the 14%. senator dodd recently went after the patients choice act because we actually make it be competitively bid without any reduction in benefits. your bill for every medicare advantage cuts 50% of the benefits out. it cuts the benefits. and so the difference is -- and i agree with the majority whip. we do need to have the savings in medicare advantage. but the way you get that is through competitively bidding it, at the same time maintaining the requirements for the benefits that are offered. there's a big difference in those two. ours ends up being pure savings to save medicare. the savings in this bill are to create a new entitlement. the other point i'd make, if

you're a senior out there listening, and if you're going to be subject to the new increase in medicare tax, for the first time in history we're going to take medicare taxes and not use it for medicare. we're going to use it for something else. under this bill, this .5% is now going to be consumed in something out-of-side of medicare. so no longer do we have a medicare tax for the medicare trust fund. we have a medicare tax that funds the medicare trust fund plus other programs. i would say to my colleagues, i think we want a lot of the same things. how we go about it, the senator from montana recognized the fact that we're going to increase payments to primary care physicians. ask yourself the question why only one in 50 doctors last year who graduated from medical school is going into primary

care? why do you think that is? could it be that the government who is setting the payment rates created a maldistribution in remuneration to primary care physicians? therefore, they choose to go where they can make 200% more over their lifetime by spending one additional year in residency rather than doing primary care. and what this bill does and what the senator from arizona is trying to do by sending this bill back is to refocus it on the fact that medicare money ought to be used for medicare. and if in fact we're going to slow the growth of medicare, can we do that without cutting benefits? and to slow the growth in this bill for 11 million americans who now have medicare advantage, you will diminish their benefits. that's out of the $120 billion that's going to come. you can't tell a senior who is in a rural area today, who is on

the economic lower rungs of the ladder, who uses medicare advantage to equalize their care with somebody who can afford a medicare supplemental policy, you can't tell them that this is not going to decrease their benefits and decrease their care, because it is. and in the bill it actually states that it's going to decrease their benefits. mr. mccain: very briefly, the senator from montana talked about the support that it gets. aarp? aarp makes more money from med cap plans than they sell to seniors. aarp should be opposing the bill but other groups like 60-plus are educating seniors. a.m.a. cut a deal to get their medicare payments addressed by increasing the deficit by $250 billion. and pharma, my god, if there is ever an obscene alliance, agreement that's been made that

would harm seniors because it prohibits -- it has the administration against the drug re-importation from canada and competition for -- so now we understand a little bit better why these special interest groups, 500-some of them have visited the white house in recent months, according to white house logs. mr. coburn: the senator would probably be interested to know, the american medical association now represents less than 10% of the actively practicing physicians in this country. the physicians as a whole in this country are adamantly, adamantly opposed to this bill. and the reason they're opposed to this bill is because you are inserting the government between them and their patient. that's why they're opposed to this bill. so you have the endorsement of the a.m.a., which represents less than 10% of the practicing doctors, actively practicing doctors in this country because not only will it increase payments, but the c.p.t. code

revenue's protected. that's the revenue the a.m.a. gathers from the payment system that continues to be fostered in this bill, which is their main source of revenue. mr. mccain: could i ask my colleague's indulgence for just a moment? as you know, the majority leader seems to appear more and more frantic as he perhaps is reading the same polls that we are that more and more americans, when they figure out this legislation, are becoming more and more opposed to it. so yesterday the majority leader came out and directly addressed me saying -- quote -- "this man talks about earmarks, but his amendment is one big earmark to the insurance industry. and in addition to that, the sponsor of the amendment -- talking about me -- during his presidential campaign talked about cutting these moneys." you know, mr. president, i hate to, i say to my colleagues, take a trip back down memory lane,

but at the time -- this was echoed by the d.n.c. spokesperson who echoed it throughout the flog sphere and the -- throughout the blogs sphere and the left win liberal blogs. on october 20 it was said he accuses mccain of cutting benefits. not true. obama is making bogus claims. a tv spot, well-funded campaign, a tv spot said mccain's plan requires cuts in eligibility or both. obama said in a speech that would receive fewer services and get lower-quality care. second ad claimed that mccain's plan would bring about a 22% cut in benefits, et cetera. and the factcheck.org claims

these claims are false based on a single newspaper report that says no such thing. mccain's policy director states unequivocally that no benefit cuts are envisioned. mr. president, i ask that this entire factcheck.org article be included in the record. and i hope that the senator from nevada will stop making false claims about what -- repeating false claims that were in attack ads throughout the campaign funded by tens of millions of dollars about my positions on health care in america, which the fact checkers found to be totally false. and the nature rarity says "mccain's plan means a 22% cut in benefits. the ad displays a footnote citing an october wall street story as his authority." factcheck.org says "the journal story makes no mention of any 22% reduction or any reduction at all."

so, i hope that among other things, may i describe this frustration that the senate majority leader would at least not repeat false accusations about what i wanted to do in the presidential campaign. and it's unfortunate. i hope that maybe instead of attacking david broder, instead of attacking me, instead of attacking others who are in support of this amendment, maybe we could have a more meaningful discussion about the facts surrounding this legislation. mr. dodd: how much time remains on both sides? the presiding officer: 30 seconds remaining. mr. dodd: the minority has 30 seconds? mr. johanns: i will speak very quickly. reality does sit in quickly.

we have looked at the impact on our nursing home beds in nebraska. we have about 13,000 beds dedicated to medicare. this will be a loss of $663 per bed. that affects real people. thank you, mr. president. the presiding officer: the minority time has expired. mr. dodd: met me yield two minutes of our time to my distinguished friend and colleague from -- mr. johanns: it is very kind of you. i appreciate that. maybe it comes from my fipple -m my time as governor, maybe it comes from my time as mayor, but somehow you've got to live with the legislation that's passed, whether it is by the federal government or whether it's at the state level, whatever. you can bounce this back and forth all day, but the reality is, these are real cuts and they involve real programs that involve real people in our states. you can describe them anyway you want. you can call them excessive

payments, you can do this, that, or the next thing. you can say, well, we're giving this our best shot. but the difficulty is, this is a high-risk venture. you are impacting, in my state, for example, and every senator could stand up and give this same speech, you are impacting the most vulnerable population in our nation, people who are in a nursing home who are medicare beneficiaries. as i said in my short statement, there are 14,061 nursing home beds across our state that are dedicated to medicare patients. we are working overtime to try to understand what this legislation does to real people. the number that we have come up with, working with our nursing home industry, is that if this legislation is passed, each bed is impacted by a loss of $663.

i will sum up my comments by reading something that was sent to me by someone who works in the nursing home industry. here is what this person says: "for the first time in my career, i am honestly questioning how much longer i can continue. to constantly be up against legislation in funding when all you want to do is make a difference in someone's life is exhausting." unquote. mr. president, this is a high-risk venture. this shouldn't be about taking our best shot. this is -- this should be about getting this legislation right. thank you. the presiding officer: the senator from connecticut. mr. dodd: mr. president, let me, if i can, again address a couple of points. first of all, i made this point yesterday but it deserves being repeated. the point that this legislation

doesn't provide any benefits to anybody until 2014 is untrue. i could spend the next few minutes describing the things our bill does immediately on the enactment of this legislation. there are tax breaks immediately for small business to be able to rediewts duce the cos -- to rede cost of health care. under our bill you're actually seeing a premium cost reduction in the small business market as well as the large group market. our legislation provides immediately closing a good part of that doughnut hole, which is an immediate benefit in the cost of prescription drugs for the editorial he will. that doesn't happen four or five years from now. it happens immediately. immediately, the idea of screenings and prevention services for americans. that is not only the humane thing to do; it is also a great cost saver. if you can identify and detect a problem early, the cost savings

are monumental. we all know that. under our plans as united states senators, we get 23 different options every year to choose, from we have that benefit. i am a beneficiary of that benefit, having identified a health care problem early through screening. that was not only beneficial to my personally because i am going to be alive for a longer period of time than otherwise, but it saved thousands of dollars in long-term medical costs if i had not identified the problem. those are simple things that are included in our bill that happen immediately. you can't be dropped by our health care carrier, as you are today. you can be dropped for no cause -- for no reason whatsoever. that is stopped immediately on the adoption of this legislation. so when i heard my good friend from arizona say there are no benefits in this bill until three or four or five years, that is just not true. and again a simple reading of the legislation would identify any number -- a long list i have here -- of benefits that happen immediately. the issue that senator baucus has raised over and over again is the issue of guaranteed

benefits under medicare, guaranteed benefits. let me challenge my colleagues to identify a single guaranteed benefit under medicare that is cut by the bill before us. there is not a single benefit under the guaranteed programs that is in any way disadvantaged or reduced as a result of this legislation. what is cut are private health care plans under the medicare advantage program. and this is the reason why we're doing this. medicare advantage overpayments cost every senior more money. a typical couple, elderly couple pays $90 more per year in part-b premiums to pay for the medicare advantage payment overpayments, even if they're not enrolled in these plans. that's $90 for every -- on average for every couple. and you get none of the benefits for it. fully, 78% of beneficiaries are forced to pay higher premiums for non-medicare extra benefits they will never see. now, again, i understand that

some people would like it have these additional benefits. i understand that. these are benefits that are provided for under medicare advantage. but 78% of our elderly are paying higher premiums so that a smaller percentage of people can get these benefits. why should 78% of the elderly in this country pay a higher premium for a smaller percentage of people under private health care plans? what senator baucus and the finance committee tried to do is to reduce those costs. those are not guaranteed medicare benefits. there's no guaranteed medicare benefit that is cut under this bill. and i defy any member of this body to find one guaranteed benefit that's reduced under this plan. i'd be happy to yield to my friend. mr. burr: i would ask the distinguished jdistinguished gem connecticut that we come up with

$23 billion worth of cuts in medicare. mr. dodd: nays not allowed. you cannot cut guaranteed benefits. mr. burr: would the gentleman yield for an additional question? is this board empowered to find $23.4 billion worth of cuts? mr. dodd: not under guaranteed benefits. that's very clear. mr. burr: if the gentleman could show me that in the language. mr. dodd: the board is prohibited, forbidden to take benefits away from seniors or increase their costs. they cannot ration care, raise taxes on part-b premiums or change medicare benefits or eligibility. couldn't be more clear. couldn't be more clear. they are absolutely prohibited from doing that. and that's the point we've been trying to make here. going after providers frankly, as we know, we have a -- hospitals will tell you themselves, in many cases, as a

provider, there are cost savings there. i'm told -- and again my colleagues who know more about these details that i do -- i'm told that it's not uncommon for an elderly person to leave a hospital and on average be given four prescription drugs in order for them to take. i'm told as well within a month or so, that average couple is not following their prescriptions very well. either they live alone or they're -- for one reason or not and they end up being reamid the. there is a -- they end up being readmitted. there is a very high readmission rate. our bill tries reduce that problem of getting readmissions to hospitals which raise costs tremendously. that's where the savings are coming from, by taking steps to try to dice the readmission rate as -- to try to reduce the readmission rate. it's trying to save money, save lives. but again i challenge -- i challenge any member to quo to p

and identify any single guaranteed benefit in this bill that is cut by medicare. there are none. 78% of our elderly should not be required to pay additional premiums to take care of a handful of other people out there who i understand why they want some of these benefits. but they ought to pay for them. i'd be happy to yield to my colleague. according to darmr. dorgan: them relates to -- mr. durbin: the first idea relates to medicare advantage. cecil partim said there is a good reason and a bad reason in politics. we her hear a lot of good reaso. senator mccain says send this back to committee and don't touch medicare vafnlgt i want to ask the senator from connecticut

about medicare advantage because some of the things i've read around the country about medicare advantage tell me that this plan run by private health insurance companies costs more than basic medicare. these companies promise us that when they got involved, they'd show us how to run a health insurance plan. they'd show us how to provide medicare benefited and save us money. some have. but by and large, if i am not mistaken, isn't the jury in -- 14% increase in cost for medicare benefits under this medicare advantage? mr. dodd: in some states it reaches 50% more. mr. durbin: when we talk about saving billions of dollars in the medicare program over the next several years, part of it is by saying to those companies who are overcharging medicare recipients, the party is over. we're going to make sure that every american who qualifies for medicare gets the basic benefits, but we will not allow these private health insurance

companies to get a subsidy from the federal government at the expense of medicare and its recipients? mr. dodd: and in charge the other 78 -- and they're charging the other 78% to ge of medicare beneficiaries to get a premium. it is neither medicare nor an advantage. quite the opposite. and you're accurate in the numbers. i want people to know, as much as we respect the colleague from illinois and his market the numbers he identifies of $14*u7b billets a costing this program -- they come from the congressional budget office. we didn't make those numbers up. that's the cost savings by modifying this program that has cost us so much, deprived the overwhelming majority of our elderly, the benefits that they get at their cost. so i appreciate very much his question. mr. baucus: is it also true that the june medpac report that

medicare advantage overpayments cost taxpayers an extra $12 billion? mr. dodd: that's correct. and again that's medpac. mr. baucus: well, that's right. that's medpac. and i think the point that the senator from illinois is making, we need to be underlying two or three or four times here and you've made it, too, senator dodd. that is, there is a huge distinction between medicare and these private insurance plans. mr. dodd: yes. i think too many of our fellow citizens hear the word "medicare advantage" and assume it is the medicare program. it is not. mr. baucus: it is not. it is a private plan. what medicare advantage is overpaying -- these insurance companies are overpaid. a lot that have goes back to the part-b -- part-d drug bill and so forth. the question is, they're overpaid. do those overpayments necessarily mean a better benefit for persons who signed up toke to for those plans? mr. dodd: no.

that's according to medpac. mr. baucus: why might that be the case? i want to understand this better. mr. dodd: because insurers, not seniors, determine how these overpayments are used. too often they're used just to line their pockets, to increase their profits, and not provide the benefits to the people who are getting it. mr. baucus: is it medicare that decides what the benefits will be for this vote? mr. dodd: no, it is not. it is the carriers that decide. mr. baucus: it is the private insurance companies? mr. dodd: yes. they're the ones who determine where the profits go. that's why it is such a misnomer to call this medicare advantage. it is anything but medicare or an advantage. mr. baucus: and it's also your nine -- the presiding officer: time has expired. mr. dodd: i would ask for two additional minutes the. the presiding officer: is there objection? mr. coburn: reserving the right to object. having two additional minutes on my side. mr. dodd: i gave someone on your side two earlier. mr. coburn: how about one? mr. dodd: make it one. but wait, i have no problem with two.

the presiding officer: without objection, the request is agreed to. mr. baucus: if i could just say to my colleagues, most seniors that pay part-b premiums under fee-for-service don't get any benefit whatsoever? mr. dodd: that's correct. none. none whatsoever. in fact, all they do get is higher premiums. mr. baucus: that's right, higher premiums. mr. dodd: 70%. almost 80% are paying more than more for a program they never get any benefit from. mr. baucus: so they pay extra and get month benefit from it. mr. dodd: so vote for the mccain amendment and you get exactly what dick durbin suggested. 70% of our elderly pay more premiums. they never get any of the benefits and the private carriers get to pocket the difference. that's a great -- that's a great vote around here. that's great health care reform. a senator: would the senator from con corporation could we characterize this as an earmark in the medicare program? mr. dodd dodd: it is -- it is to ears. in one ear, i give it two ears. mr. brown: senator dodd, we remember two years ago when the insurance carriers went to the government and said we can do

something -- it later became medicare advantage. they said we can do it for 5% less than the cost of medicare. and government unfortunately made the agreement with them to sign up to do that. now they -- then what happened in the last ten years, the insurance lobbyists came here and lobbied the bush administration and lobbied the e congress and got bigger and bigger payment. and it really is a subsidy for the insurance companies. and you say -- and senator baucus and senator durbin said it's not a form of insurance, it's a privatized form of medicare that serves the insurance companies very well, thank you, but doesn't really serve the seniors this in this country. mr. dodd dodd: and i'll sit herl day for someone to cite just one benefit under medicare cut. just one. there are no guaranteed benefits cut under medicare advantagement and nor can they be cut. our legislation bans and prohibits any cuts in guaranteed benefits. mr. durbin: mr. president, i have six unanimous consent requests for committees to meet during today's session of the

senate. approved by the majority and minority leaders. and i ask unanimous consent these requests be agreed to and they be printed in the record. the presiding officer: without objection. mr. coburn: mr. president? the presiding officer: the senator from oklahoma. mr. coburn: one of the questions and one of the promises was if you have what you -- what you have now and you like it, you can keep it. what's happening under this bill for 11 million seniors on medicare advantage is not going to happen. if they like it, they're not going to be able to keep what they have. you can't deny that. that's the truth. medicare advantage needs to be reformed. there is no question about it. i agree with it. and as the senator alluded to the patients' choice act, we actually save $160 billion into the patients choice act but we don't diminish any of the benefits. and we do that because c.m.s. failed to competitively bid it because when it was written -- and i understand who wrote it -- when it was written, we didn't make them competitively bid it. so you could get the same

savings, exactly the -- actually you could get more savings and not reduce benefits in any amount if you competitively bid that product. but we've decided we're not going to do that. second point i would make with my colleagues is the vast majority of people on medicare advantage are on the lower bottom of the economic. they can't afford an aarp supplemental bill. they can't afford to pay an practice $150 or $200 a month. and so what most of the time happens with medicare advantage is we bring people up to what everybody else in medicare gets because most people can afford -- 84% of the people in this country can afford to buy a medicare supplemental policy because medicare doesn't cover everything. so your idea to try to save money, i agree with. but cutting the benefits, i don't agree with. and you're right, senator dodd, the basic guaranteed benefits have to be supplied in medicare advantage and then the things above that, which you get with a

supplemental policy of which you can afford to buy, is what these people get. and what you're taking away from the poorest of our elderly is the ability to have the same care that people who can afford to buy a supplemental policy. that's the difference. thank you. and i -- i do appreciate my chairman for his courtesy in yielding the time. the presiding officer: under the previous order, the senate stands in recess until 12:30 p.m.

you heard some discussion on the floor about an amendment by the republican democrat by women's health screenings. live coverage when senators gavel back in on c-span2. you can find out more about the senate health care bill and the health-care hub. information about amendments as well as previous day's for comments at c-span.org/healthcarol. this afternoon on c-span3, looking into the afghanistan strategy. committee members will hear from secretary of state hillary clinton, robert gates and joint chiefs of staff chairman admiral mike mullen. live coverage starting at 1:30 eastern. they will be returning to capitol hill to speak to the senate foreign relations committee and the house armed services committee. the morning hearings starting at

9:00 a.m. on c-span.org. we take you live to a house hearing on breast cancer screening recommendations. we will hear from officials on the medical panel that recently recommended against mammograms for women under the age of 50. this got underway at 10:00 a.m. this morning. we join it live in progress. >> i disagree with what some of my colleagues from georgia said i have great respect for his real-world experience on these health issues and appreciate the concern he brought to this hearing but i also want to talk about the comments made by the chairman emeritus and others on this committee. if people don't believe that rationing takes place right now in our private insurance system, everyday and every state and every congressional district,

they are sorely misguided. it does happen every day under the current system which is failing to meet the needs of the american people. i will give you an example of a friend of mine who is diagnosed with prostate cancer and conferred with his position -- physician and treatment options and agreed proton beam therapy was the best choice of treatment for him and he went to his private insurance company which also is the medicare administrator in my state of iowa and his treatment was denied on the basis that it was experimental. guess what? under the medicare plan the same private insurance company administered it was considered non experimental and even though he was eligible for medicare because of his age he was still covered by a private plan through his employer and was denied coverage for the same treatment he would have gotten had he been a member of medicare. that is what is wrong with our broken health care delivery system and that is why

comparative effective research is such a critical part of a rational discussion about health care policymaking. in an earlier hearing in the same subcommittee i talked about a hearing that took place in this very room years ago when a researcher advocating high dose chemotherapy with bone marrow transplants for breast cancer patients was the only path to q or those women even though it had not been tested by rigorous academic research. than, years after that, we came to the realization that many women were actually harmed and died because of being subjected to that treatment. that is why it is so important that the plain language amendment that i put in the health care bill be implemented in people dealing with health care issues.

in its position paper, the u.s. preventive services task force highlights why that is so important. they indicate on one page of their statement that the problem was a matter of communication because they did not say what the task force meant to say, the communication and recommendations were poor. i agree with that. just look at the next two sentences to find out why. they say we said screening starting at age 40 should not be automatic nor should it be denied. that doesn't make sense. the next sentence says what we are saying is that a decision to have a mammogram for women in their 40s should be based on a discussion between a woman, her doctor. if you don't communicate for your intended audience in language that they can comprehend easily, the barriers of communication between highly technical scientific and medical information will be a problem.

but the debate we are having is a healthy debate about what the most effective use and treatment for breast cancer patients is. that is what we need to focus on going forward and i yield back my time. >> next is the gentleman from utah. >> i will be brief because i am looking forward to hearing from our two panels on this topic. the incidence of breast cancer is lower in utah than most states that our mortality rate is high because women in utah diagnosing cancer at later stages. as a witness on our panel notes in his testimony the recent recommendations provided by the u.s. preventive services task force has sparked concern and disagreement among providers, patients, and public discourse has led to further confusion and anxiety. as we can see from the testimony in this committee there is no

consensus on screening protocol but there is more consensus than screening discussions as an individual one between the provider and patient. i hope today's hearing can provide information on the evidence based decision making process. also interested in the cancer community and medical providers and their next step for our region patient education and the limitations of the screen. thank you, mr. chairman. i yield back my time. >> i believe that concludes the opening statements by members of the subcommittee. i will now turn to our witnesses. the first panel will come forward. i would appreciate it. thank you. we have two witnesses from the u.s. preventive services task force. to my left is dr. ned colange

and next to him is dr. diana b. pettitti -- pettitti -- pettitti -- vice chair of the task force. i will mention, you know we have five minute opening statement from you that become part of the record and each of you may submit additional statements in writing for inclusion of the record and i recognize first, dr. colange. >> on behalf of our fellow task force members thank you for the opportunity to discuss the task force and our work. i published recommendations on breast cancer screening and drew a lot of attention. we recognize what the recommendations say it was for. the timing of the release was unfortunate. we had to explain these

recommendations and clarify what we intended to say to clinicians and women. the health care clinicians' scientist on a task force will be a understand most personal experience, the impact of breast cancer on the lives of women and their families. our job is to rigorously reviewed scientific evidence, politics play no part in our process. that was never considered in our considerations. we voted on these recommendations long before the last presidential election. the timing of the release of the findings last month was determined not by us but by the publication schedule of the medical research journal which peer review our work. the task force was created by a congressional mandate as an independent body with the mission of reviewing the scientific evidence for clinical preventive services and developing evidence based recommendations for the health care community. our primary audience for recommendations remains primary care clinicians. the task force has 16 volunteer members representing a diverse

array of expertise in primary care and preventive health related disciplines including adult, child, preventive and behavior medicines, women's health and researching methods. ahrq recommends from public nomination process. given the scope of topics covered specialists to consult on care for those identified through screening by primary-care clinicians may not necessarily be recruited as members but instead are consulted to review and comment on our work at critical points in the process. our current portfolio includes a broad array of 105 services listed on our web site. we strive to update topics every five years which is what prompted the new breast cancer screening recommendations. to address the topic, designated task force group members and scientists had an evidence based practice center collaborative we developing a framework and pertinent key questions.

constructed systematic review of evidence each key question is conducted and evidence record is created with group consultation. based on the evidence review and explicit methodology, the work group drafted recommendations statement and added an in person meeting. the evidence in the draft statement presented and discussed and the task force votes on the recommendation. there is a careful attention to conflicts of interest so that members with potential conflicts are refused from session and vote who otherwise are restricted in participation. representatives of 24 partner organizations including all primary care specialties, key federal agencies and other stakeholders specified in written testimony and on our web site are invited to participate in the discussion. at three t points in the process, dr. sent for review and comment by the partner organizations, by specialty expert consultants from the relevant area such as oncologist

and other -- professional organizations and advocacy groups. these products include the analytic framework and key questions, systematic evidence review and a draft recommendation statement as voted on. all comments are considered in creating the final product. final statements and evidence reviews are published in peer reviewed medical journal. recommendations are expressed based on two factors only. the magnitude of net benefit or balance of benefits for providing the service and the scientific certainty about whether a service works. cost and cost-effectiveness are not addressed in our deliberations in making a recommendation. over the past several years we discussed whether costs should every influence recommendation and repeatedly said no. for these recommendations there's sufficient health benefits such as primary care clinicians recommended to provide the services for all appropriate patients.

if there is no net benefit or no net harm we assign recommendations to not provide the service. if gaps in the evidence prevent benefits from being determined we assigned by statement reflecting insufficient evidence indicating that more research is needed. finally, another recommendation is a sign when there is a small net benefit. for c recommendations we recommend the patient be informed about the benefits and hard and be supported in making his or her own informed choice about being tested. the specific language we recommend against routine provision was intended for consideration by primary-care clinicians. unfortunately it has played out in an unintended way in the public interpretation of the breast cancer recommendation. congress and public law section 915 convene a task force to address our mission. the role is to support our

activities and processes. staff and a director of age are q. do not vote or otherwise influence our decision. have to read knit to the committee that breast cancer is of particular concern to me. i lost my mother-in-law to breast cancer and my sister is currently undergoing therapy. a totally understand this issue and have to rely on the science as we provide our recommendations. i would like to turn testimony over to dr. petitti to testify specifically about the breast cancer screening. >> i would like to thank dr. calonge and act -- ask dr. petitti to begin. >> i'm vice-president of the task force degrees only physician and epidemiologist. i have spent my entire 32 year curr yr as a scientist working on issues of women's health. i published on the topic of

mammography screening. i served as vice chair of the national cancer policy board and have the expertise and evidence, systematic review -- i participated in this process from the very beginning. i would not sign off on any recommendation that i did not believe reflected the best possible use of evidence for the benefit of women. i appreciate the opportunity to clarify for members of this subcommittee, the task force recommendations and evidence and waving of the evidence that led to these recommendations. in specific the task force recommends the following -- women age 5374 should have mammography every other year. the decision to start regular annual screening mammography before the age of 50 should be an individual one and take asian context into amount including the patient's thou use regarding specific benefits and harm. that is the task force saying

screening starting at 40 should not be automatic or denied. many doctors and many women perhaps even most women will decide to have mammography screenings starting at age 40. the task force support those decisions. the task force acknowledges the language used to describe its recommendation about breast cancer screening for women 40 to 49 did not say a what the task force meant to say. the task force is committed to communication. we have the topic in 1989. the task force recommended screening women 40 through 75 every 1 to two years. with screening younger women, the task force stated it may be prudent to begin screening at an earlier age for women at high risk of breast cancer. 1996 the recommendation was in favor screening women 50 to 59

everyone to two years, memo mccarthy screening was given a c grade and the recommendation was insufficient evidence. in 2000 to the task force recommended screening women 40 to 69 everyone to two years stating the benefits were smaller and took longer to emerge for women who were first screened in their 40s. on november 16th the task force issued its updated recommendation on breast cancer services. i wish to clarify that the timing of the issuance of these recommendations in late 2006. discussion of a plan for updating the recommendation began. the breast cancer topic came up for review at the regularly scheduled time. work on the topic started in 2007. when the recommendation statement came up for a vote in november 2007 the members could not come to agreement about what to recommend because agreement about what to say about the balance of benefits and harm in

this context the task force asked for additional evidence from its evidence based practice. the task force considered is evidence that its july 14th to 15 meeting. in making its final recommendation the task force considered evidence identified in the systematic review of evidence for 6 key questions. result of an analysis for the breast cancer screening and results of a study commissioned by the task force and cut by the intervention surveillance modeling network the systematic review identified three thousand -- three thousand studies and many were used to make recommendations. the final recommendations were made based on a weighing of the benefits and arms for the mammography. the task force concluded from the evidence screening mammography for women 45 to 64 as a benefit in reducing deaths due to breast cancer. the benefit is larger in older women than in younger women. i would like to speak specifically to the issue of

harm in this net benefit equations. preventive services are provided to eight symptomatic individuals for the sole purpose of preventing or delaying morbidity, delaying functional decline or death. the promise of service delivery is net benefit. benefit-harm. the benefits of mammography have been easy to communicate. the harms and potential harms have been difficult to communicate. the easily identifiable and commonly used definition of harm is physical injury. these physical injury direct arms are very small. the task force considers the harm of a screening test not just physical harm but psychological harm. a great deal of disagreement of the controversy has centered on the task force use on consideration of anxiety and psychological death -- distress as a harm of a false positive

test. in particular, the psychological distress has been ridiculed. to understand the consequences of all positive tests it is necessary to consider how women enter the screening cycle, what happens and what might happen to a woman who has a positive test. no matter how hard the concept of screening is explained, a positive mammogram screening test -- until cancer is proven not to exist. for some women who have a positive test the time between a positive test and statement there is no cancer is mercifully short. for other women the follow-up involves more than one additional test, clinical breast examination and a test over a period of time that is not always short and over a period of time that is unpredictable and not within the control of the woman. some women eventually need a biopsy. cancer is a terrifying prospect that carries special emotional

weight because the consequences of a diagnosis have in the past involved not only death but the prospect of mutilating surgery. anxiety and psychological distress in women who have had positive screening tests is amply documented in the evidence. the task force wants the screening mammograms to be done with full knowledge of these potential harms, the frequency of these harm than what is to be gained by being screened and earlier compared with a later age. false positive tests are more frequent in younger than older women. other faults -- other arms of mammography include ones that are less well documented. some women are diagnosed in their 40s with cancer that could have been treated as well as diagnosed later. these women may have been exposed to the harms of treatment including surgery, chemotherapy -- >> i don't want to stop you but it is so important, your two minutes over. >> i am only going to say my

final statement. mammography starting at 40 should not be automatic. the task force recommends women in their 40s decide on an age to begin screening that is based on conversation with their doctor and individuals. i apologize for going over. >> i will apologize for trying to stop you because it is so important that you clarify a lot of these things and i appreciate that. our procedure now is that we have questions from the members of the panel -- from the members of congress and i will start with myself. let me say that you have actually clarified some of the questions i was going to ask very well but i want to review this if i could in my own mind. if i say anything you disagree with, tell me. i do want to ask you some questions as well. there are a lot of myths that

have been spread both today and certainly in the last few weeks since you came out with your recommendation and the way i understand it, the current task force uses these ratings, the same ratings that would be used under the different task force that is in the legislation, the larger health care reform legislation. you are the u.s. preventive services task force and the bill we passed has a different name, clinical preventive services. the ratings are the same or similar. but right now these ratings have no force. they are just recommendations. what some of my colleagues have said is insurance companies don't have to cover a, b, or c. they don't have to cover anything. a lot of insurance companies don't prefer to cover any screenings because if you do a screening and they have to pay

for treatment it cost them money which they try to avoid. what i see right now is in some cases states have required certain screening like my own state but on the other hand we heard the gentleman from utah talk about utah where my understanding is they don't require any screenings. the point i am trying to make is the big advantage of the health care reform bill that we passed hr3962 is will create minimum standards to require benefits. private insurers would be required under that bill to cover services with a grade a or b recommendation. right now they don't have to do anything. what we are saying is that a minimum, if you or your successor task force says that this a or b is, has to be required. the other thing is the secretary could ree