covered under a public option or private insurance claim. my understanding is the new task force -- the secretary under the bill could even require c reading under the basic benefit package. that is contrary to some of my colleagues on the other side of the aisle. the truth is if it is enacted into law it would result in a lot of people who are not getting mammograms, pap smears, colonoscopy is, a lot of people don't get that all because insurance companies don't have to do it unless the state requires it. now under this bill they will do anything you rated, the secretary could even require it in the public option or the private plan under the basic

benefit package. about line is women's ability to obtain mammogram's increases in these house and senate bills that are being passed. when i look at the republican bill on the other side, there would be no minimum required benefits under the republican bill. essentially it would be just like the status quo that we have now. i listened to the debate we had today and the bottom line is the bill that we passed in this house provides a lot more coverage, lot more guarantee, status quo doesn't provide any guarantees that the federal level, norwood with their republican alternative we have been given on the other side. my question is you mentioned when you recommended this, it says it has a small net benefit and women are supposed to make their own -- you made it quite

clear, there is some net benefit and secretary -- that is required as well. you are not in any way with the recommendations saying the screening is not a good thing. you are actually saying there is a net benefit but you would like individual women to make that decision with their doctor because it is only a small benefit. is that accurate? ..

>> if you rated at the peak it has to be done that if you rated as a ceda secretary says it has to be done. right now there is nothing, nothing at all. the republicans and their

alternative, they continue the status quo saying he don't have to cover anything. and i just appreciate because i think it helped me clarify. i yield no to the gentleman from illinois. >> thank you, mr. chairman, because what we need in this country is a continued debate on failed health care bills that we passed on the floor of the house. that's what we really need to do and that's what we are doing today. and we're using obviously what happened through your process to make the claim, the short-term of a public option, which many of my colleagues on the other side have said is the gateway to a one payer system. so when the government controlled all the health care decisions in this country, they will eventually default to control costs through rationed care. now the process, the scientific process that you just admitted to, says there is a small net

benefit. when there is decreased revenue available, the default will be based upon 3962, just what you say on your website. your website recommends against routine screening mammography in women age 40 to 49. do you think that this statement would be perceived by younger women younger than 50 that they should not get a mammogram? on your website. >> we have communicated very poorly about the c. recommendation. it is clear that many women, many physicians, and certainly the media interpreted that language as if we were recommending against women in their 40s ever having a mammogram. that was not our intention. >> i understand, but we are concerned of commissions. we are concerned of bureaucracy.

we are concerned up ration and care. we're concerned about bureaucrats saying there's no real net benefit. and then, yeah, that is right that exactly what we are concerned about. that's why we are having this debate. in the bill, in chairman pallone, i think pretty adequately talked about the differences. we know that services with a rating of a and b. must include in a sensual benefit package. in this case with the highest rating of women would not receive currently, if this were law, as it is today, women and the c. category would not receive this as a covered benefit. under 3962. and that is part of our concern. and this does segue into the fold health care debate. the commission on part of the, and i don't have the whole 2000 pages. i just pulled out excerpts.

the commissioner shall specify the benefits to made available under exchange which is the health benefits plan during each year. and then you can go further on. basic enhanced and premium and then the premium plus. a., approved by the commissioner. and then you can go to the c-section which i can, highlighted. and we continue to have preventative services including those services recommend with a by the task force for clinical preventive services. so this is, again for a lot of us, and important debate. do any of you know an individual who has been diagnosed for cancer between the ages of 40 and 49? personally. >> i know many individuals who have been diagnosed with cancer.

>> mr. calonge? >> just. >> and any other question, what about over the age of 74. anybody been diagnosed? >> yes. >> because although we are focusing on 40 to 49 annual report, over 74 has the i category and we don't even know what that is. so what are we saying to those over the age of 74? >> i speak to the evidence and the mapping of the evidence to the task force recommendations. >> and i appreciate that and i'll have 38 seconds. i'm going to be punctual on my time. par this concerned with h.r. 3962, is as we said the public option the gateway to one payer system, eventually ration care, and then a decision made based upon the financial ability of this country to fund, care, across the spectrum, but also

our seniors in our country. and again, this incomplete aspect for 74, bespeaks to the concern that it you are elderly in this country and we get to a one payer system, there will be decisions made not based on health care, add-on cost that i yield back my time. >> thank you. mr. waxman, chairman waxman. >> thank you, mr. chairman. the health care bill that the republicans are complaining about is not law. yet, your agency presented a task force is in operation. this is set up -- is it set up under law? >> yes. >> and your job isn't to make recommendations to insurance companies, is it? >> that is correct. >> your job is to make recommendations on preventive services so that the latest science, and information about the side, is communicated to

clinical practitioners, isn't that your job? >> that is correct. >> and this is very useful information. now, we are focused on the breast cancer issue. but that's not the only area where you have made recommendations, isn't that the truth? >> that is correct. >> how many other areas has the task force made recommendations in the last couple of years, let's say? >> our current portfolio is 105 total, and we take up around 15 new or updated topics in yuli. >> you have recommended that teenagers be screened for mental illness? >> yes. that was a new recommendations this year, congressman, that we just came out with. so this is new services that have not been recommended prior. >> and it was a breast-feeding behavioral intervention recommendation? >> that is correct. >> and you had a recommendation that asked for the prevention of cardiovascular disease, a way to prevent this disease is that right? >> correct specs are you had how

many, 103? >> one hundred five total. >> one hundred five total. i am assuming that none of the others in this controversial as this particular one. >> that is correct. >> so we had a controversial issue, because it challenges accepted notion about the frequency of the breast cancer screening. and we're going to hear a lot more about that in the next panel. but i want -- let's look at the challenges being raised by some of the republicans. which i think it's all political. they are acting as if your recommendations based on bringing the scientist who had the expertise, which are directed at clinical people will be used to ration care. that is their argument that we're going to ration care. and they did say well, that's because there's going to be a health care bill that will provide the requirement for minimum benefits. now, there will be many benefits in that it should have access to

hospital. should have access to doctors. you should have access to pharmaceuticals are your area is in the preventive area, and nothing could be more important to me than having the latest science on how to prevent diseases. because if we can prevent illnesses, we won't pay to treat them later. your task force will continue in operation. you will convene a scientist who are experts in different areas of prevention. now, i guess the question i'm not raising this too, but the question is how will your recommendations affect the minimum benefits that will be required for health care insurers? health care insurance can be a public insurance, if that survives in this legislative process. it could be private insurers. by the way, private interest doesn't have to provide by your recommendations, isn't that true? >> that is correct. >> some of them cover the preventive services and some of

them don't, isn't that your? >> that's correct. >> is their decision. but if we're going to provide subsidies to get insurance and were going to try to get a market where insurance companies compete against each other, on price and quality, we are to make sure that all of them provide at least a minimum set of benefits. one of the issues for republicans is to have a lot of insurance plans that don't provide any minimum benefit at all. they can be cheaper if they don't provide minimum benefits. well, i find that troubling. let's say we're going to a minimum benefits and you make a recommendation. is your recommendation under the proposed bill automatically going to be in effect for all insurance? do you know whether that to be the case? >> congressman, i'm not well -- >> you're not an expert on the

bill. let me explain what the new bill will do. the new bill will take your recommendations. they will go to the secretary. the secretary will review them. the secretary will have a notice of rule and comment and a public process. and then decide whether there's a minimum benefit. now, a minimum benefit is a minimum benefit. it is not a maximum benefit. so if there is a recommendation, as you have proposed on breast cancer screening, that would be not a requirement of insurance to do no more than that. would be a recommendation that will be required that will require insurance companies to do that as a floor, not a ceiling. i just wanted to set this up because i think some people watching this hearing may get confused when they hear stories about bureaucrats or rationing care, or the health care bill being a gateway to single-payer.

we expect the bill of competition and people to make choices between insurance plans, but we don't want the choice is between insurance plans to be those who cover breast cancer screening and those who don't. but those with at least a minimum of preventive services that we can hope will prevent diseases and need for paying for care for those instances. thank you, mr. chairman. >> thank you, chairman waxman. next is the gentleman from texas domenech to burgess. >> thank you, mr. chairman. let me ask you a question. i thought the clinical guidelines, and i guess this is a reprint from the annals of internal medicine. the last page of which is an appendix which lists the members of the u.s. preventative tasks services. there's a number of individuals

of listed there. their specialties are not. is anyone on the list there a board-certified ob/gyn? >> yes. there are two board-certified o.b. gm's on the task force. and that is a usual day that we usually have two. snack which are those two that are on the list that i have in front of the big? >> kimberly gregory and wanda nicholson. >> and they both participated in this decision? >> kimberly gregory was on the task force when this decision was voted. wanda was not. there was another ob/gyn on the task force when this topic was voted. that was it george who is the professional ob/gyn at university of california san francisco. >> with these unanimous vote? >> no. that you both were not unanimous. >> do we know how they voted? >> i can't recall. that is in the record, and we

could make that information available to the committee if that is important. >> i would like to see. i don't know if the committee will deem it important that i resort to appreciate the opportunity to see it. now, is there a radiologist in this group? >> no. no, there is no radiologist in this group. >> is that a problem? >> the expertise of this panel has been called in question. the experts are individuals who have experience in screening, signed in prevention. radiologists were consulted and reviewed. the documents and the recommendations and provided input. >> let's wait until that finishes. it bothers me also. on the -- on this task force, the majority of these individuals were primary care doctors, was there a surgeon on

the board or on the task force? >> well, there again, the experts are experts in primary care and prevention. and yes, there were and i would have to count them. for primary care physicians on the task force. kirtley and four at the time of the vote. >> was a general surgeon who specialized in localization and breast biopsy? >> no, there wasn't. they were consulted. >> they were consulted, all right. i apologize for being in and out, but we were doing like nine simultaneous hearings today. financial services makeover requires some attention and thought as well. on the issue though of talking about, you said you factored in the psychological events surrounding a callback on a positive mammogram. you factored in the psychological cost. if you will, to the patient of that exchange. did i understand that correctly?

>> the issue was a qualitative assessment. anxiety, psychological distress, inconvenienced are all considered to be potential harms. and again, it is part of the net benefit equation. >> when i was in school back in the 1970s, i realized this was a long time ago, but mammogram at screening was not at least in the area where i went to school. that was not something that was done. uses of atomic mammogram. it was kind of a big deal if you felt something, but it wasn't -- it was part of the routine screening. in fact, i don't think, as i recall, looking back it was probably the mid '80s when that became a standardized screening test. in fact, in texas i don't know whether this is true nationwide, but i know in texas women can self confer for mammography. when that all happened, that

psychological cost was one of the arguments that was used by people who felt that routine screening would not be a good idea. so how is it that we have come to the point now where we have rejected back in the 1980s, but now a 2009, this is a factor again that is worthy of our consideration? >> again, this is not determined information that we want women to know about it we want to know -- them to know how common it is. again, the polls positive rate is much lower, as women get older. and that is part of the yet risk-benefit equation. we would not want women to be afraid of having a mammography. this is again one piece of information that women in the physicians should discuss when deciding when to start screening. >> is that same rationale of why

the self-examination? >> the task force recommended against clannish and teaching women's breast self-examination. they did not recommend that women not pay attention to their bodies. that they ignore loans, or that they ignore problems that might come up when they find a love. again, the task force recommendation was against doctors teaching women breast self-examination. well, how are women supposed to get that knowledge? if they can't just get by intuition, someone somewhere along the line has got to provide them some guidelines. some proper time to do the exam and how to do it and what to be concerned about. and whatnot to be concerned about. as i recall, i maybe wrong on this but i don't ever recall coding and being compensated for

teaching breast self exam. i wasn't a cost driver. my own inference from that could be that we were worried about people would find things that lead to procedures and were better off we don't ask, don't tell. >> again, the evidence -- them into very well conducted randomized clinical trials in which women were taught how to do breast self-examination, and both of those trials found no overall benefit in terms of reducing mortality for breast cancer. again, we go to the evidence. 's package him as time has expired. >> as i said in my opening statement, -- >> mr. burgess, you are over two minutes over. >> it doesn't strike me -- >> mr. burgess. >> again, as a young -- >> doctor burgess. your time has expired.

>> i'll be interested in what some of the other clinicians tell us. i thank the chairman. >> doctor burgess you are almost three minutes over and we are about -- i think we have time for one more set of questions. and then we're going to vote. we have five votes. we will take one more set of questions and then we will adjourn and come back after the five votes. next is chairman dingell, did you want to proceed in a? >> i think i can proceed rather quickly, mr. chairman. yes, please. i would like to welcome you both just me and say how helpful it is to have you here. from the things i've heard said on the other side of the aisle about you folks at the agency, i was afraid you would appear with horns, tales, fangs and in a red suit breathing fire. demanding that we immediately terminate all health benefits through the unfortunate segue war and especially with regard to mammograms and pap smears. so i'm very much comparable and i want to welcome me to the

committee this morning. i just have really one question that i think is important. i find it curious that the task force has repeatedly over the years voted to leave costs out of its deliberations on whether to provide or not approved preventive service. >> thank you. congressman, i think this is a key question. the task force believes its major charge from congress and responsibility to primary care clinicians and patients is that evidence-based stake in the ground in new and from how much it costs to achieve the benefits associated with a given effective preventive service. >> so your short answer is that you are recommending the needed services, the needed tests, the

needed treatments as opposed to looking at the cost, is that it's? >> that is correct. >> now, to assist my college on the other side of the aisle, and they do this with great affection and effect to charity. you addressed this question in your statement, and you say here, and i read this for the benefit of my college on the other side, you say task force recommendations are based on consideration the health benefits and health harms and providing the preventive service and on the scientific certainty of whether preventive service works. costs and cost effectiveness of specific prevention services are not addressed by the task force in its deliberations. then you say this. the task force only, and that's underlined, considers the scientific evidence and health benefits and health harms that the task force is specifically discussed whether costs should

influence recommendations, and has repeatedly voted to leave costs out of deliberations on whether or not to provide a preventive service. is that right? >> that is correct. >> no, when your recommendations are made, are they used to put a ceiling on benefits, or are they used to describe a minimum level of the benefits that people should get? >> congressman, i must admit that outside of the scope of our recommendations how they are used by other entities to. >> okay. now, your recommendations are not expected to be substituted for the need of the patient, or the concerns and expertise of the doctor. and they are not intended to intrude into the doctor patient relationship.

am i correct in that interpretation or am i wrong? >> that is correct. in fact, if you read our statement as published in the annals, it says the task force recognizes that clinical or policy decisions involve war considerations in this body of evidence alone. clinicians should understand evidence and individualized decision-making to the specific patient or situation. is actually proceed all recommendations and the recommendation statement that we expect conditions to do what they are trained to do in order to address the needs of the individual patient for his or her best interest. >> now you do permit as the task force goes about its business to have different agencies and persons of concern present in the deliberations, is that not so? >> that is correct. >> in your deliberations are public? >> at this point, the deliberations of a task force

vote are by invitation only. >> but by invitation. you don't get to people who come in and listen. they can go and see what's going on, and they are also permitted to make comments to you on the task force, is that not so? >> we actually invite comments from our partners to help us do our job better, and to take into consideration different viewpoints and different issues. >> and you allow citizen input? >> the task force is currently moving towards increased private citizen input with the resources we have available to consider and identify those. we have, prior to this time, done more with input through specific groups that we invite to comment because we think they are important stakeholders. this is an issue that the task force believes that in the interest of enhanced transparency and responsibility

to the american public and the patients, whose physicians may consider our recommendations, needs to be improved. >> thank you, mr. chairman. thank you. >> thank you, chairman dingell. we have five votes. i would say about an hour, but when they are done we will come back in reconvene. the committee stands in recess. [inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] >> so this hearing taking a break now. members going on the house floor, and hear on c-span2 we will be returning to the senate momentarily. senators expected back falling about an hour-long recess to continue the health care debate. elsewhere on the c-span networks this afternoon on c-span3, the house foreign affairs to be looking to president obama's afghanistan strategy. committee members will hear from secretary of state hillary clinton, defense secretary robert gates and joint chiefs chairman admiral mike mullen. live coverage at 1:30 p.m. eastern. now live back to the u.s. senate on c-span2. on monday the congressional budget office sent a letter to

the senator from indiana, senator bayh, that provides a very comprehensive analysis of -- a comprehensive analysis of what health insurance premiums will look like as a result of this 2,074-page bill that we have before us that's been introduced by senator reid. now, listening to that discussion, i'm starting to wonder if anyone actually read the letter. i hear a lot of people saying that this letter proves that premiums will go down under the reid bill even though that's not what the letter says. so i'm here to tell my colleagues what the letter the really says. the letter says, and makes it very clear, that premiums will increase on an average of 10% to 13% for people buying coverage

in the individual market. so since it seems to fly by everybody, what this letter actually said about increasing premiums, i brought down a chart to show everyone just in case you missed it, and the -- the letter and the -- from the c.b.o. says very clearly that for individual market, premiums are going to go up 10% to 13%. now, my colleagues keep saying that premiums are going to go down conveniently, forgetting then to mention this 10% to 13% increase. they prefer to talk about the 57% of the americans in the individual markets that are getting subsidies. so it is true. the government is spendin

spending $500 billion of hard-earned taxpayers' money to cover up the fact that this bill drives up premiums faster than current law. so we might as well treept. premiums will go up -- well repeat it. premiums will go up faster under this bill. supporters of this bill are just covering this increase in cost, how? by handing out subsidies. if you're one of the 14 million that doesn't happen to get a subsidy, you're out of luck. you're stuck with a plan that is 10% to 13% more expensive and also sie simultaneous an unprecedented manual law that mandates that you purchase insurance. and if you don't purchase

insurance, you're going to pay a penalty to the i.r.s. every time you file your income tax. some may say this is just the individual market. it only accounts for a small portion of the total market. well, if you're comfortable with 14 million people paying more under this bill than they would under current law, let's look at the employer-based market. congressional budget office analysis says that this bill maintains the status quo in the small group and large group insurance market. now, is that something to really to be celebrating. our ex peck -- are expectations so low at this point that my friends on the other side of the aisle are celebrating that this bill will increase premiums for some and maintain the status quo for everyone else?

and i'm being generous in using the phrase status quo. because this bill actually makes things worse for millions of people. this bill is so bad that my friends on the other side of the aisle are trying to convince the american people that this is just more of the same. -- more of the same when that doesn't happen to be the case. whatever happened to bending the growth curve? now, if that's too washington-ease for people, the goal around here of a bill at one time was to make sure that the inflation in insurance didn't continue to go up so much that it would go the other way. and then what about the president's promise that

everyone would save $2,500? now, according to the congressional budget office almost every small business will pay between 1% more to 2% less for health insurance. that means, of course, that compared to what businesses would have paid under current law, this bill will either raise premiums 1% or decrease them a whopping 2%. that doesn't sound like this bill is providing any real relief or for sure not providi providing $2,500 savings for every american as president obama repeatedly pledged during the campaign. and larger businesses will pay the same or up to 3% less for

health insurance. once again, that doesn't sound like relief. it sounds like more of the same. in fact, the congressional budget office has confirmed that between now and 2016 premiums will continue to grow at twice rate of inflation. i thought congress was considering health reform to put an end to the unsustainable premium increases. so this bill cuts medicare b by $500 billion, raises taxes by $500 billion, restructures 17% of our economy, and spend spends $2.5 trillion and, yet, some of my colleagues on the other side of the aisle are really celebrating that they have achieved the status quo when, in fact, the situation will be worse.

i always thought the status quo was unacceptable. i thought businesses couldn't afford the status quo. i thought the status quo was killing american businesses, killing jobs, and making this country less competitive. but member after member keep coming down to the floor to celebrate $2.5 trillion -- celebrate spending $2.5 trillion on the status quo. we could have done that for free. am i missing something? did people really read the same letter that i did from the c.b.o.? now when president obama visited minneapolis in september, he didn't sound like he was celebrating maintaining the status quo. on the contrary. and i have a chart with one his quotes.

"i will not accept the status quo. not this time. not now." well, some members seem to disagree. some members are celebrating that they're making things worse for millions of americans and maintaining the status quo for everyone else. and here is what vice president biden said, and i quote -- "the status quo is simply unsettable. let me say that again. the status quo is simply unacceptable. rising costs are crushing us." end of biden quote. that doesn't sound like a call for more of the same. but, once again, members on the other side of the aisle seem quite comfortable investin investing $2.5 trillion in more of the same.

that's taxpayers' dollars that we're talking about. and i think if i asked most iowans how they feel about the government spendin spending $2.5 trillion, premiums will still increase fast or faster, they'd say that was a pretty bad investment. well, i'm not going to argue with what our qepts woul constid say on that point. i agree with them. this congressional budget office tells me that we're debating a pretty bad investment. our constituents want lower costs, that is their main concern. but this bill fails to address that concern because it raises premiums. and despite offering new ideas throughout the committee process and on the floor, republicans are being accused of supporting the status quo. well, c.b.o. has spoken and it's pretty clear that my colleagues are not only okay with the

status quo, they're okay with making things worse. higher taxes, higher premiums, increased deficit, less medicare. they're celebrating that they spent $2.5 trillion to raise premiums for 14 million people. also not bending the growth curve of inflation in health care and not cutting costs. don't take my word for it. read the letter. read the letter from the congressional budget office. because i had copies that i'll pass out if anybody wants them and i have this chart to demonstrate that point. i'd also like to take a few minutes at this time to correct some inaccurate comments that were made earlier by some of my

colleagues. when we're talking about 17% of the economy and something that touches the lives of every single american, i want to make sure that we have an honest and accurate debate. this morning i heard at least three members on the other the aisle say that medicare advantage is not part of medicare. this is totally false. but don't take my word for it. i'd like to have you turn to page 50 of the handbook, "medicare and you" is the handbook. it has the date of 2010 on it. so it's sent out every year. in fact, i think i've got two copies of in this my household, if anybody wants to save paper and not waste taxpayers' money, you can get on the internet and

tell them to send only one to your house next year. and i've done that. so this book says for those who say that medicare advantage is not part of medicare, i quote -- "a medicare advantage plan is not health coverage choice that you may have as part of medicare." end of quote. directly from page 50. i repeat, despite what members were saying earlier, the "medicare and you" handbook says very clearly medicare advantage plans are part of medicare. so if you're cutting medicare advantage benefits, you are, in fact, cutting medicare. if you're cutting medicare advantage benefits, you're, in fact, cutting medicare benefits. next i hear a lot of members talking about guaranteed benefits v. statutory benefits.

i can't speak for my other 99 colleagues. but the seniors in iowa who have come to rely upon the free flu shots, eyeglasses, dental care that medicare advantage provides, don't really care if they're guaranteed or if they're statutory. seniors in iowa just want to know that they're still have these benefits after health reform is passed. also the senator from connecticut challenged any member to come down to the floor and point out where this bill will cut benefits. he even read a section from page 1,004 of the bill -- page 1,004 of this 2,074-page bill that talks about how the medicare

commission cannot cut benefits or ration care. well, i have read page 1,004, and what senator dodd failed to mention is that this section only refers to part-a and part-b of medicare. it fails to provide any protection to medicare part-d, the prescription drug benefit, or the medicare advantage program that covers 11 million seniors. are we now going to start hearing that medicare part-d isn't part of medicare either? in fact, on page 1,005, it specifically says -- the medicare commission can include recommendations to reduce medicare payments under parts c and d, end of quote. now i've asked c.b.o. and they

have confirmed that this authority could result in higher premiums and less benefits to seniors. in fact, this is what the congressional budget office director elmendorf said -- and we have that on a chart for you to see, the quote that i'm going to read -- "a reduction in subsidies to part d would raise the costs to beneficiaries." lastly, i want to raise an issue about access to care. i keep hearing my friends on the other side of the aisle talk about how these cuts won't affect seniors. they say they are just overpayments to providers. well, in my opinion, if you can't find a doctor or if you can't find a home health provider or a hospice provider to deliver care, then that tends

to be a very, very big problem. i'd even consider that a cut in benefits or hurting access to care. but once again, don't take my word for it. in talking about similar cuts to medicare in the house bill, the office of actuary, the center for medicare and medicaid services said providers who rely on medicare might end their participation. and we have another quote that we'll put up here, so here's where the quote goes. "possibly jeopardizing access to care for beneficiaries." so let's be accurate and let's be honest. medicare advantage is part of medicare, and this bill cuts benefits as seniors -- that

seniors have come to rely upon. the medicare commission absolutely has authority to cut benefits and to raise premiums, and this bill will jeopardize that access to care those are all facts. they are not my facts, but facts taken directly from the language of this 2,074-page bill and from reports of the congressional budget office and reports of the center for medicare services actuary. i yield the floor. and if nobody wants the floor, i'll ask for -- okay. mr. durbin: madam president? the presiding officer: the senator from illinois. mr. durbin: madam president, it seems i'm following the senator from iowa every day. i first want to say my friendship and respect for him, but the medicare advantage program which the republican side is trying to protect is a

program which is private health insurance. the largest opponent, political opponent to health care reform in america is the private health insurance industry. we estimate that they have spent spent $23 million so far lobbying to defeat this bill because they are doing very well under the current system. they are very profitable companies. they realize that if they face competition and limitations on the way they do business, it will cut into their bottom line and profits, and naturally they are fighting this bill. the amendment before us, motion to commit by senator mccain, the first thing it does is to protect the medicare advantage program. that is a private health insurance program that was created with the promise that it would be cheaper than traditional government-run medicare. in some cases, they've offered a cheaper policy, but overall these private health insurance

companies are charging the medicare program 14% more than the actual cost of the government-run system. the promise that the private sector could do it more cheaply and better turned out not to be true, and so we're paying a subsidy in profits, extra profits to private health insurance companies. the mccain amendment which has been supported by senator grassley and others who have come to the floor is an effort to stop us from eliminating this subsidy. what is this subsidy worth? this subsidy to private health insurance companies will cost the medicare program program $170 billion over the next ten years. no small amount. we believe that money is better spent on extending benefits to medicare beneficiaries, not in providing additional profits to already profitable private health insurance companies. yes, medicare advantage policies

are offering medicare benefits, but they're charging more for it than the government, so it didn't turn out to be a bargain. it turned out to be a loss to the medicare program. they didn't do what they promised to do. we want to hold them accountable. the mccain amendment wants to let them off the hook and basically say private health insurance companies, keep drawing that money out of medicare. we're not going to hold you accountable. that earmark of the medicare advantage program, that decision by congress to give them a special privilege in selling this health insurance is too darned expensive for senior citizens and people who rely on medicare, and that's why we're opposing the mccain amendment. and i might add -- this is the third day of the debate on health care reform in america. we have yet to vote on a single amendment because the republicans refuse to allow us to bring an amendment to the floor for a vote. how can you have an honest debate about a bill of this seriousness and magnitude if you can't bring a measure to a vote

on the floor? those who follow the senate know that it's a peculiar institution and its rules protect minorities and individual senators can object to a vote. the republican senators have objected to a vote even on the mccain amendment, which i believe was filed on monday and here we are on wednesday. we've talked about it. we know what's in it. we should vote on it. but the republicans don't want to vote on it. they want to drag this out in the hopes that our desire to go home for christmas means we'll walk away from health care reform. well, if a few of the republican senators could have just left the democratic caucus, they would know better. we are determined to bring this bill to a vote. we are determined to bring real health care reform to this country. we know what's at stake. the current health care system in america is not affordable for most americans. health insurance premiums have gone up dramatically in cost. individuals can't afford to buy a policy. businesses are dropping coverage

of their employees, and we know that the costs are unsustainable. unless we start bringing those costs down, this great health care system is going to collapse. we need to preserve the things that are good in the system and fix those that are broken and affordability is the first thing we need to address. the second thing we need to address, quite obviously, is to make sure that every american has the right as a consumer to get coverage when they need it. how many times have you heard the story of people who paid their health insurance premiums their whole lives, then somebody gets sick in their house, a new baby, a child, your wife, your husband, a big medical bill is coming. you go to the health insurance company and you're in for a battle. they won't pay it. they say oh, we took a look at your application you filed a few years ago. you failed to disclose that you had acne when you were an adolescent. am i making that up? no, that's an actual case. and because you didn't disclose

that you had acne as an adolescent, you failed to disclose a pre-existing condition, so we have no obligation to pay for anything. if this sounds far-fetched, believe me, it's an actual case and many others just like it. insurance companies, private insurance companies spend a fortune hiring an army of people sitting in front of computer screens, talking to the people who are paying the premiums, and above their computers is a sign that says "just say no." and they say no consistently because every time they say no, their profits go up. but it leaves individuals and families in a terrible situation. denied coverage because of a pre-existing condition, denied coverage because they couldn't carry their health insurance policy with them after they lost their job. denied coverage because of a cap in the amount of money that the policy would pay. rescinded where they walk away from an insurance policy because of some objection they have, legal objection. or how about one of your kids who turns age 24, no longer covered by your family health

plan, now out on their own, maybe fresh from college and not having a job and no health insurance. this bill addresses those issues. this bill eliminates the concern people will have over pre-existing condition. it takes away the power of the health insurance companies to say no. it finally creates a situation which we have waited for for a long time. america is the only civilized, industrialized country in the world where a person can die for lack of health insurance. it doesn't happen anywhere else. only in america, 45,000 people a year die for lack of health insurance. who are these people? let me give you an example. one that i met. her name is judy. she works in a motel in southern illinois. she is 60 years old. delightful, happy woman. she is the one who takes the dishes at the end of this little breakfast they offer at the motel. couldn't be happier and nicer. 60 years old with diabetes. never had health insurance in

her life, never. goes to work every day. works 30 hours a week. makes about $12,000 a year. she doesn't have health insurance, but she does have diabetes. and she said to me, you know, if i had health insurance, i would go to the doctor. i have had some lumps that have concerned me for a little while here, but i can't afford it, senator. that's an example of a person who doesn't have the benefit of health insurance. this bill that we're talking about, this bill that we are going to produce here for everyone to read on the internet. it's already there. been there ten days already. it will continue to be there. this bill will make sure that 94% of the people in america have health insurance coverage. that is an all-time high for the united states of america. i might also say that despite the criticisms -- and they are entitled to be critical on the republican side of the aisle, they have yet to answer the most basic criticism i have offered. where is your bill? where is the republican health care reform bill? they can't answer that question

because it doesn't exist. they have had a year to explore their ideas and develop them, but they have failed. they cannot produce a bill. they are for the current system as it exists that is unsustainable, unaffordable, leaving too many americans vulnerable to health insurance companies who say no and too many americans without health insurance. i want to address one particular issue that seems to come up all the time, and it's the issue of medical malpractice. i know my republican colleagues are going to bring that issue up. senator mccain has, many others have as well. president obama recently recognized this as an issue of concern. our bill will as well. we are going to explore, encourage, and fund state efforts to find ways to reduce medical malpractice premiums and to reduce even more importantly the incidents of medical errors. medical malpractice reform

proposals are based in states. the federal government doesn't have a medical malpractice law, not in general terms. it does for specific programs like indian health care, for example, or federally qualified clinics, but when it comes to the general practice of medicine, that is covered by state laws, and the states decide when you can sue, what you can sue for, and the procedures that you have to follow. in almost every state, there has been a system that's developed over the years to handle these cases. states regularly change and update their laws. the states try to strike a balance to protect patients, preserve the hospitals and doctors and other medical providers and ensure that those who are injured have a chance for compensation and to manage the costs of their system. 24 states as of last year have decided to impose caps on noneconomic damages in medical malpractice cases. a long time ago before i came to

congress, i used to be a practicing lawyer in springfield, illinois, and i handled medical malpractice cases, so i don't profess to be an expert nor even have current knowledge of medical malpractice , but i did in a previous life have some experience. i defended doctors when they were sued for a number of years on behalf of insurance companies, and i represented plaintiffs who were victims of medical negligence. so i have been on both sides of the table. i have been in the courtroom. i've gone through the process. here's what it comes down to -- if you were a victim of medical malpractice, medical negligence, the jury can give you an award which usually includes a number of possibilities: pay your medical bills, pay for any lost wages, pay for any additional expenses that may be associated with the court case, and pay for pain and suffering. those are the basic things that are involved in a medical

malpractice lawsuit. the pain and suffering part of it -- pain, suffering, scars and disfigurement -- is an area where many states have said we want to limit the amount you can recover for pain and suffering, what they call noneconomic losses. it isn't medical bills. it isn't lost wages. so my state, for example, has a limitation of $500,000, a medical malpractice case recently enacted by our general assembly. the state of texas, $250,000. those are so-called caps, limitations on the amount of money a jury can award for pain and suffering when they find, in fact, you are a victim of medical negligence. now, some states have decided to establish caps on pain and suffering, how much you can recover. others have not. and the reason many impose caps was because they wanted to bring down the cost of medical malpractice insurance for doctors and hospitals. well, a number of states have

done that. 24 states have done that. and we've been able to step back and take a look. how did it work? if you put a cap, a limitation for roarve, pain and suffering, noneconomic loss, does that mean there will be lower malpractice premiums for doctors? in some cases yes. in some cases no. minnesota's an interesting example. minnesota doesn't have caps on damages yet has some of the lowest malpractice premiums in america. 26 states, including minnesota, use certificate of merit, which means before you can file a lawsuit, you need a medical professional to sign an affidavit that you have a legitimate claim before you even get into the court. that's in minnesota. it's in illinois and a number of other states to stop so-called frivolous lawsuits. some states, like vermont, have low malpractice premiums and don't have any malpractice reforms. it's just hard to track cause and effect here between tort reform, malpractice changes and

the actual premiums charged physicians. there are ways congress can help states build on what already works. senator baucus, who's here on the floor, is chairman of the senate finance committee. he has worked with senator enzi to create a program, state -- incentives to state programs to look for innovative ways to reduce malpractice premiums and the incidence of medical negligence. i think that that is a good idea and i that it will ultimately be included in this bill. one of the major considerations when it comes to malpractice reform is making sure we focus on real facts. one myth that we hear over and over again is about frivolous lawsuits flooding the courts. i've heard many colleagues come to the floor and call it jackpot justice, frivolous lawsuits, fly-by-night lawyers filing medical malpractice lawsuits. those are -- i'm sure there's anecdotal evidence for each and every state, but when you look at the record, you find that

malpractice claims in lawsuit pay -- and lawsuit payouts are actually decreasing in america. in 2008, according to the kaiser family foundation, there were 11,025 paid medical malpractice claims nationwide. one year in america, total number of medical malpractice claims paid according to kaiser family foundation, 11,025. there are 990,000 doctors in america, so roughly 1% of doctors are being charged with malpractice and paying each year. this is a decrease from 2007, where the number was 11,478. so the number of malpractice claims has gon gone down. the number of paid claims for every 1,000 physicians has decreased from 25.2 in 1991 to 11.1 in 2008. that's a little over 1% of doctors actually paying malpractice claims.

not only is the number of claims decreasing, but the amount they're paying to victims is decreasing as well. the national association of insurance commissioners -- not a group that is biased one way or the other when it comes to plaintiffs or defendants -- said in 2003, malpractice claim payouts peaked at $8.46 billion. in 2008, that number had been cut in half. in five years, it went down from $8.4 billion to $4 billion. so rather than a flood of frivolous lawsuits, fewer lawsuits are being filed and dramatically less money is being paid out. incidentally, "the new york times" did a summary of research in september of this year and found that only 2% to 3% of medical negligence incidents actually lead to malpractice claims. so it's not credible to argue that we have this flood of malpractice cases -- they're going down -- or this flood of payouts for malpractice in america -- it's been cut in half

in five years. a third key consideration in this debate is cost. one of the main goals in pursuing health care reform is to try to reduce the cost in the system and we want to try to do that in a way that won't compromise quality care. there's been a lot of talk about the congressional budget office report that was ordered up by senator hatch on october 9. the congressional budget office for years said that they could not put a price tag on medical malpractice reform in terms of savings in the system, but on october 9 and reported to senator hatch that they could. they -- senator hatch asked th them, what would the impact on our health care be if we had a texas cap -- which is $250,000 for pain and suffering. i see the senator from texas on the floor, and i hope i'm quoting the texas law correctly. he was a farmer texas supreme court justice. am i close? mr. cornyn: close. mr. durbin: close. that's all i'll get for the senator from texas "close." the fact is, senator hatch said

to the c.b.o., what if we had the texas-style cap on every state in the union, what would be the net result? and they came back and said there would be a savings of over $50 billion over the next ten years. they said, 40% of the savings would come from lower medical liability premiums; 60% through reduced utilization of health care services. now, i don't question the congressional budget office reaching that conclusion. they've worked hard to come up with their figures. but there are other ways to reach results that they want to achieve without lowering medical -- pardon me, of lowering medical liability premiums and saving overall health care expenditures rather than adopting federal damage caps. keep in mind, these caps on what you can recover are for people who have been judged by a jury of their peers to have been victims. these are not people who have just said, i think i was hurt. we're talking about people who

have a right to recovery in a lawsuit, who are being told even though you were hurt and somebody did something wrong, we're going to limit how much you can be paid when it comes to these noneconomic losses. the c.b.o. analysis that senator hatch received went on to say, "because medical malpractice laws exist toal patients to sue for damages that result from negligent health care, imposing limits on that right might be expected to have a negative impact on health outcomes." they cited one study which said that a 10% reduction in cost related to medical malpractice liability would increase the nation's overall death rate by .2%. by calculation, that means that if the hatch proposal were applied nationwide, according to the c.b.o. and this cited study, 4,853 more americans would be

killed each year by medical malpractice. this is c.b.o. report. or more than 48,000 americans over a ten-year period of time that the c.b.o. examines. so if you accept their projection on the savings for medical malpractice reform asked for by senator hatch, you cannot escape the fact that they say, yes, you'll save money but more americans will die. because they'll there will be more malpractice. let's look at the savings that can be achieved through reduced malpractice insurance premiums. c.b.o. said a $250,000 federal damage cap would reduce overall malpractice premiums by about 10% and would reduce overall health care spending by .2%. do we need a federally mandated cap to achieve that? malpractice insurance premiums are already going down. according to the medical liability monitors comprehensive survey of premiums, in the areas of internal medicine, general surgery and ob-gyn -- and i

quote -- "the most recent three years have shown a leveling and now a reduction in the overall rate charge" for medical malpractice premiums. there was a time in the early 2000's where malpractice premiums were going up dramatically, 20% a year in 2003, 2004, 9% in 2005. since then, they've gone down each year, by less than 1% in 2006, by .4% -- i'm sorry, .4% increase in 2007 but a 4.3% decrease in 2008. that's without any federal cap on damages. let's also consider the issue of defensive medicine. many people claim that doctors do things -- order tests, cover themselves -- because they're afraid of being sued. i agree that there are undoubtedly some doctors that think that way. there was a famous article that was printed in the "new yorker" where a doctor, a surgeon from boston, dr. galandi, went to

mcallen, text -- you probably saw this, senator cornyn -- and he wanted to know in this article why in mcallen, texas, they were paying more for medicare patients than any other place in the united states. and so he visited with doctors and surgeons and hospital administrators to ask them why. what is prospect about that city and its elder -- what is peculiar about that city and its elderly people? he sat down with the doctor and the first doctor said, well, it's defensive medicine. we're -- we're doing all these extra tests and extra costs to medicare to cover ourselves and protect ourselves. a doctor sitting next to him said, oh, come on. with the texas law, nobody's filing malpractice lawsuits around here. we're doing these extra proashz because -- extra procedures because it's a fee-for-service system -- you're paid more when do you more. so at least in this days cais, there was a dispute as to whether this was truly defensive

medicine or just overbuilding. dr. carolyn clancy, in the h.h.s., has called national errors a national problem of epidemic proportions. according to that agency, the rate of adverse events has risen about 1% in each of the past six years. the institute of estimated in 1999 that up to 98,000 people died in america due to preventable medical errors. these medical errors cost a lot. a 2003 study by the "journal of the american medical association" found that medical errors in u.s. hospitals in the year 2000 -- just one year -- led to 3 2,600 deaths, at least 2.4 million extra days of patient hospitalization, and additional costs of $9.3 billion. i'd like to also say a word about the medical malpractice insurers. remember, insurance companies and organized baseball are the only two businesses in america

exempt from the antitrust laws. what it means is that insurance companies can literally legally sit down and clued and conspire when it comes to prices they charge. and they do. they have official organizations. used to be known as the insurance services offices, that would sit down to make sure every insurance company knew what the other insurance company was charging and they could literally work out the premiums, how much they charge. the same thing was true where market allocation -- with market allocation. insurance companies, unlike any other business in america, can pick and choose where they'll do business. company x, you take st. louis. company y, you take shi of chicago. chicago. company z, you take, columbus, ohio. they can do it legally. so the obvious question is, if this isn't on the square in items of competition from health insurance companies, are these companies in fact paying out the kind of mean they should? i'm going to see if i can find a chart here. the staff was nice enough to bring them here.

well, i can't. they're great charts but i can't find the one i'm looking for at this moment. according to the information for the national association of insurance commissioners, in 2008, medical malpractice insurers charged 11.2% in premiums but only paid out $4.1 billion in losses. in other words, they took in $7 billion more than they paid out in losses. that's a loss ratio of 36%, which means they're basically collecting $3 for every $1 that they pay out, pretty close. how does that compare to the rest of the insurance industry? well, it turns out that private automobile liability insurance had a loss ratio of 66%, payout of $2 out of every $3. homeowners, $72%. workers comp insurance, 65%. these medical malpractice insurance companies are holding back premiums and not paying them out. it reached a point in my state where our insurance commissioner ordered that they declare a

dividend and pay back some of the premiums they collected from doctors and hospitals when it came to malpractice insurance. but rather than get lost in statistics, as important as they are, i think it's important that we also talk about the real-life there's are involved in medical malpractice. i hear these terms like frivolous lawsuits and jackpot justice and people, you know, taking advantage of the system. but let's not forget the real-life stories that lie behind medical malpractice. let me show you a picture here of a couple. it's molly acres of new lennox, illinois. a lovely young lady with her husband. molly acres had a swelling in her breat -- her breast, and wea doctor who performed a biopsy that showed that she had breast cancer. molly had several mammograms which found no evidence of a tumor but the doctors decided that despite the mammograms, she must have a rare form of breast cancer. and so they recommended a

mastectomy, removing molly acres' right breast. after the operation, the doctor called her into the office and said that on further review, she never actual had breast cancer. the radiologist had made a mistake. reviewed her slides and accidentally switched molly's slides with someone else. molly was permanently disfigured by an unnecessary surgery. she said afterwards, "i never thought something like this could happen to me but i know now that medical malpractice can ruin your life." by the way, that other woman, whose slides were switched with molly's, was told she was cancer-free. what a horrific medical error that turned out to bement -- to be. this next picture is of glen steinberg of chicago. he went into surgery for a removal of a tumor from his abdomen. after the surgery, glen was having severe problems.

the doctors x-rayed him, they found a four-inch medical retractor left over from the surgery. the second surgery was performed to remove the medical piece, during that surgery, glen's lungs aspirated and he died. his wife said, not a day goes by that i don't miss glen's companionship. because of gross negligence, he was not here to support me when our son went off to serve our country in iraq. this group of kids includes martin heartnet. i met martin. he's from chicago. martin's mom arrived at the hospital to deliver him, but her labor wasn't progressing, her doctor broke her water and found out it was abnormal. rather than considering a c-section, donna's doctor administered a drug, six hours later she had not delivered, but the fetal monitor system

indicated that he was in severe distress. the doctor performed an emergency c-section, but it was another hour before donna was taken to the operating room. during that time the doctor failed to give oxygen to help martin breathe much after martin was born, he was in intensive care for three weeks. later it was learned that martin had brain damage and cerebral palsy, a -- directly from not getting the oxygen. donna's doctor told her not to have anyone children because there was a serious problem with her d.n.a. that could result in similar disabilities for her kids. since then she has given birth to three perfectly healthy son. donna sued the doctor for martin's delivery and received a settlement. he is thankful that the settlement covers the care that

is not covered by health insurance, a wheelchair accessible van and $100,000 in changes to her home so that her son, martin, can get around the mouse his wheelchair. what would she have done without the money from the -- when we say there's an absolute limit to how much someone who has created a problem has to pay out, we have to think about in terms of real-life stories like martin. martin's going to live for a long time and he's going to need help for a long time. someone needs to be responsible for that. the person who is cause -- who caused it should be responsible. when you establish an artificial cap on noneconomic losses on pain and suffering, then you're saying there is a limit to how much can be paid. i recall a case of a woman in chicago who went into a prominent hospital, one i have a great deal of respect for, to have a mole removed from her face, a simple mole removal. they gave her a general

anesthesia and in the course of that general anesthesia, gave her oxygen and the oxygen tank, the administration, caught fire burning off her face, literally. she went through repeated reconstructive surgeries. i've met her. scarring, and, as you can imagine, a lot of pain. $250,000 too much money for that? for what she went through? her life will never be the same. that is the kind of disfigurement that is covered by noneconomic losses that would be limited by medical malpractice. there are better ways to do this. we can, in fact, reduce the cost of medical malpractice insurance. we can, in fact, reduce medical errors. we shouldn't do it at expense of innocent victims. people who went with all the trust in the world to doctors and hospitals and had unfortunate and tragic results. every time i get up to give a speech on this subject, i you

always make a point of saying, and i will today, how much i respect the medical profession in america. there isn't one of us in this chamber or watching this who want point to men and women in the practice of medicine who are true hero heros in their every s lives, who sacrifice to become doctors who work night and day to get the best results for their patients. they richly deserve not only our praise, but our respect. but there are those who make mistake, and serious mistakes. there are innocent victims who end up with their lives changed or lost because of it. we cannot forget them in the course of this debate. this is about more than dollars and cents. it's about justice in this country. so i urge my colleagues on the issue of -- when the issue of medical malpractice to come before us, to remember, of course, the doctors, but not to forget the victims and their families. i yield the floor. mr. cornyn: madam president? the presiding officer: the senator from texas. mr. cornyn: thank you, madam president. while our colleague from illinois is still on the floor,

let me say to him, i always enjoy listening to him. he's one of the most effective advocates. he's an outstanding lawyer. he and i frequently disagreerks but i always enjoy listening to his arguments. i would just say -- and this isn't what i came to talk about. i'm glad i happened to be here when he talked about the successful effort that we had in texas that we had through medical liability reform laws, to make medical liability insurance more anordable for insurance, and, as a consequence, increase the number of doctors who have moved to our state, including rural areas, which has increased the public access to good quality health care. we've seen in 10 100 counties we an ob/gyn, 100 counties didn't have an obstetrician after medical liability reform, that has changed dramatically, along with other high-risk specialties, that moved to these counties where they were afraid

to go due to risk of litigation and what that might mean to their future. so this is an important topic. and i hope we have a chance to talk about it more. so i appreciate the senator raising the issue. we do have a difference of view about it. if we can save $54 billion and still allow each of these people who were harmed by medical negligence to recover, which, in fact, they would be under the texas cap on noneconomic damages, each of these individuals will be able to recover their lost wages, their medical bills, they'd be able to receive up -- large amounts of money for pain and suffering. i'm sure not enough to compensate them for what they've been through. but no one should understand that these individuals would somehow be precluded or the courthouse doors would be shut to people who are victims of medical negligence. but there needs to be some reasonable limitations that will

help in the end, make health care more accessible, which is, of course, what we're here talking about. i want to focus briefly on the cuts to medicare and this new huge piece of legislation that we are considering. of course, we're told by the congressional budget office that, as a result of medicare cuts and the huge number of tax increases, that this bill is -- quote -- "paid for," in other words, assuming the assumptions that the congressional budget office took into account, which, of course, span for tean-year budget -- span for a 10-year budget window and are almost never true in the end. if you take that by faith that we're going to raise health care by half a trillion dollars and cut medicare by half a trillion dollars, this is a medicare

neutral bills. what we're saying to america's seniors, those who are already vested in the medicare program, that we're going to tak take $464 billion that would go into the medicare program and we're going to use it to create a new government entitlement program. now, our record of fiscal responsibility when it comes to entitlement programs is lousy, to say the least. we know that medicare and social security, another entitlement program, and medicaid have run up tens of trillions of dollars in unfunded liabilities. most of them are riddled with fraud and waste and abuse. the question that i have and i think many have is: why in the world would you take money out of the medicare program that is scheduled to go insolvent in 2017 that has tens of trillions of dollars in unfunded liabilities, why would you take almost half a trillion dollars out of medicare to create yet

another entitlement program that no doubt will be -- will have many of the problems that we see now under our current entitlement programs? it just does not make sense if you are guided by the facts. and, of course, then we have our colleagues on the floor who said, well, we can cut $464 - -- $465 billion out of medicare, and you know what? medicare beneficiaries won't feel a thing. well, i don't think that's possible when you cu cut $135 billion from a hospital -- from hospital payments, when you cut $120 billion out of medicare advantage on which 11 million seniors depend -- on which they depend for their health care. when you cut $15 billion from payments to nursing homes. another $40 billion to home

health. i think one of the most effective ways of delivering low-cost health care in people's homes, you cut $40 billion from that. and you cut $8 billion from hospice, where people go during their final days in their terminal illness. now, some of my colleagues have claimed that these cuts won't hurt patients, but many people, including me, disagree. as a matter of quote to quote president obama's own medicare actuary, the actuary said providers might -- said providers might end their participation in the program. in other words, like in medicare now in my state 58% of doctors will see a new medicare patient because reimbursements -- payments to providers are so low. which means 42% won't see a new medicare patient. in travis county, a austin, tex,

the last figures i saw showed that only 17% of physicians in travis county will see a new medicare patient because reimbursement rates are so low. yet, we're going to take money from medicare to create a new entitlement program. and there's no question in my mind that it will -- that providers in the words of the medicare actuary might went. in fact, i think he's hedging his bets, i think will end -- many will end their participation in the program and, thus, jeopardize access to beneficiaries muc. well, we heard some of the debate earlier on when our side of the aisle made proposals to fix some of the problems with the medicare program. not to create a new entitlement program by taking this amount of money -- $464 billion from it. but when we tried to fix it earlier, some of our colleagues, including the distinguished majority leader, called those cuts immoral.

and cruel. well, to quote president obama on the campaign trail, he was one of those who criticized senator mccain for some of the proposals that he made to try to fix the broken medicare program. and -- and as we have heard from the texas hospital association, the medicare cuts to hospitals simply won't work because this is another sort of accounting trick that here in washington, d.c., and congress people think, well, we can get away with this and fool the american people into actually what is happening. but here on the senate bill, and people are not fooled. people are a lot smarter than i think members of congress sometimes give them credit for. but under the senate bill, the senate bill's expanded coverage does not start until 2014. but the hospital cuts begin immediately.

well, i've talked about the broken medicare program and, frankly, i think a lot of people would rather see us fix medicare and fix medicaid before we create yet another huge entitlement program that's riddled with fraud, that is on a fiscally unsustainable path and one that, frankly, promises coverage, but ultimately denies access to care because of unrealistically low payments to providers. we're going to make that worse if this bill passes, not better. well, this bill also includes something else that i think the public needs to be very, very aware of. it uses not only budget gimmicks, so our friends who support this bill can say that it extends the life of the medicare trust fund for a few years. the problem is it isn't solve the fundamental immeant bankruptcy of -- imminent bankruptcy of medicare. that's one of the reasons that

the bill sponsored by the distinguished majority leader creates a new, unaccountable, unelectable board of bureaucrats to make bureaucrats to make burtsdzer puts to the -- brewer accurates to the medicare program. so cuts as i said to pay for a new entitlement, it creates a board of unelected, unaccountable bureaucrats, the so-called medicare advisory board, sounds innocuous, that they've been given tremendous power to budget targets to meet another $23 billion in the first year alone. and if congress does not substitute those cuts with other cuts or to providers of benefits, the board's medicare cuts would go into effect automatically. that would mean medicare patients and physicians and hospitals and everyone else that depends on medicare would have no say in what happens to personal medical decisions

because they would just be cut and shut down by this unelected appointed board. the government charted boards of experts we have in existence today aren't always right. we may remember the medicare payment advisory commission, so-called medpac, which was created by congress in 1997, has recommended more than than $200 billion in cost cuts in the last year alone that congress has not seen fit to order. in other words, this medpac board makes recommendations now and congress is then left with the option in its wisdom to act to make those cuts or not, and congress has said no to the tune of $200 billion in the last year alone. and then there is another relatively notorious board of experts, unaccountable, faceless, nameless bureaucrats that we've learned a little bit about in the last few days. the u.s. preventative services task force. the u.s. preventative services

task force. now, they're supposed to recommend preventive services, but just recently said that women under the age of 50 don't need a mammogram to screen for breast cancer. respected organizations like the american cancer society and the coleman advocacy alliance disagreed based on their own rigorous review of the latest medical evidence. as the father of two daughters, i can tell you i don't want my wife or my daughters restricted in their access to diagnostic tests that may save their life. if their doctor recommends in his or her best medical judgment that they get that test. yet, what we have here is that in the future if the medical advisory board is passed is an unelected, unaccountable board of bureaucrats who can make cuts which will ultimately, based on -- quote -- expert advice, which will ultimately limit access to

diagnostic tests, including things like mammograms which became very controversial. the secretary of health and human services came out immediately and said we will never allow that to go into effect. well, not even the secretary of health and human services under this -- under this provision could reverse the decision of this unelected, unaccounted board which may well -- i would say probably will in some cases limit people's access to diagnostic tests and procedures that could save their life. even though their personal physician in consultation with that patient may say this is what you need because when you give that power to the government, not only to render expert advice, but then to decide whether to pay or not to pay for a procedure, then the government -- namely some bureaucrat here in washington, d.c. -- is going to make the decisions based on a cost-benefit analysis. okay. on a cost analysis, we can

afford, according to the decision of the u.s. preventative services task force, we can afford to lose women to breast cancer, women between the age of 40-49 because we don't think they need a mammogram. and on a cost-benefit analysis, they may say tough luck. but that's not, i think, where we should go with this legislation. many health care providers are concerned about the medicare advisory commission. according to a letter today, -- a letter, excuse me, from 20 medical specialty groups, they said -- "we're writing today to reiterate our serious concerns with several provisions that were included in the health care reform bill, and to let you know if these concerns are not adequately addressed when the health care reform package is brought to the senate floor, we will have no other choice but to oppose the bill." and included in those concerns was the establishment of an independent medicare commission whose recommendations would become law without congressional

action. according to a letter from the american medical association today, the a.m.a. policy specifically opposes any provision that would empower an independent commission to mandate payment cuts or physicians. further, the provision does not apply equally to all health care providers, and for the first four years, significant portions of the medicare program would be walled off for savings. this is an example of another trade association that basically decided to cut a deal with the administration behind closed doors, and they had been prevented from some of these cuts under this medicare commission while physicians have not been accorded similar treatment and they don't think it's fair. they think it's unfair, and i agree with them. this letter goes on to say -- "in addition, medicare spending targets must reflect appropriate increases in volume that may be a result of policy changes,

innovations in care, that improve care, create greater longevity and unanticipated spending for such things as influenza pandemics. these are crucial issues with the potential for significant adverse consequences for the program which must be properly addressed through a transparent process that allows for notice and calming. it sounds to me like the american medical association thinks this is a lousy idea, and i agree with them. artificial budget targets that the medicare advisory brd would have to meet leave virtually no ram for medical innovation. you know, it's unbelievable what medical science in america and across the world has done to increase people's quality of life and their longevity as a result of heart disease, for example. people who would have died in the 170's are living today healthy because they're taking prescription medications that

keep their cholesterol in check, and they have access to innovative surgical procedures like stents and other things that can not only improve their quality of life but their longevity as well. if we have the medicare advisory board saying huh-uh, we're not going to pay for some of these things, it will crush medical innovation and have a direct impact on quality of life and longevity. what if we were to find a cure for alzheimer's in the year 2020 but because the -- this board says it's too expensive, we're not going to pay for it, you're out of luck? what if there are things we can't anticipate today, which we know there will be because whoever heard much about h1n1 virus or swine flu just a year ago? some of my colleagues have said a, quote, independent board like the medicare advisory board would insulate health care payment decisions from politics. the very charter of the medicare

advisory board was a result of a deal cut behind closed doors with the white house, a political deal, and it's got a lot of reasons why, as you can tell, i don't think it's going to work well. according to "congress daily," hospitals would be exempt from the board's acts, according to committee staff and hospital representatives because they already negotiated a cost-cutting agreement with the chairman of the finance committee and the white house. it's something we worked out with the committee which considered our sacrifices, said richard corsch, spokesman for the federation of american hospitals. a spokeswoman for the american hospital association reiterated that hospitals receive a pass. they were protected from four years of cuts based on on $155 billion cost-cutting deal already in place. now, is that the kind of politics we want to encourage behind closed doors deals cut to protect one sector of the health

care industry and sacrifice another while denying people access to health care? now, that's the kind of politics i would think we would want to avoid. the truth is the reid bill gives more control over personal health decisions to washington, d.c., where politics will always play a role in determining winners and losers when the government's in control because people are going to come to see their members of congress and say will you help us? we're your constituents. and members of congress are always going to be -- try to be responsive if they can within the bounds of ethics to their constituents. but this needs to be not a process that's dictated by politics but on the merits and on the basis of preserving the sacred doctor-patient relationship. if we really want to insulate health care from politics, we need to give more control to patients, to patients, to

families, to mothers and fathers, sons and daughters to make health care decisions in consultation with their physician, not nameless, faceless, unaccountable bureaucrats. now, madam president, i filed an amendment to completely strike the medicare advisory board from the reid bill, and i would urge my colleagues to support it at the appropriate time. the medicare advisory board empowers bureaucrats to make personal health decisions instead of those patients whose power to determine their own future in consultation with their doctor we ought to be preserving. the medicare advisory board is an attempt to justify the half trillion dollar pillaging of medicare from america's seniors to create a new entitlement program. we should fix medicare's nearly nearly $38 trillion in unfunded

liabilities, not steal from a program that's already scheduled to go insolvent in 2017 at a time of insolvent entitlement programs, record budget deficits and unsustainable national debt, this country simply cannot afford a $2.5 trillion spending binge on an ill-conceived washington health care takeover. i yield the floor. a. a senator: madam president? the presiding officer: the senator from new hampshire. mr. gregg: it is the tradition in this body that a senator seeking recognition gets recognized, is it not? the presiding officer: the senator from california was here earlier. mrs. feingold: my understanding was, mr. president, that we alternate and go from side to

side. mr. gregg: madam president, i believe i have the floor. the presiding officer: the senator from new hampshire. mr. gregg: i would ask unanimous consent that at the conclusion of the senator from california's remarks that i be recognized. the presiding officer: without objection, so ordered. mrs. feingold: madam president? the presiding officer: the senator from california. mr. feingold: i admire senate's gentility. thank you very much. madam president, i rise to say a few words on behalf of the mikulski amendment, but before i do, i want to make a generic statement. those of us who are women have essentially had to fight for virtually everything we've received. when this nation was founded, women could not inherit property. women could not receive a higher education. in fact, for over half of this nation's life, women could not vote, and it was not until 1920, after perseverance and demonstrating that women achieved the right to vote.

women could not serve in battle in the military, and today we now have had the first female general. so it has all been a fight. senator mikulski and senator boxer in the house in the 1980's began this fight or carried this fight. those of us in the 1990's that came here, added to it. you, madam president, have added to it in your remarks earlier. mrs. feinstein: the battle is over whether women have adequate prevention services provided by this bill. and so i want to thank senator mikulski and senator boxer for their leadership and for their perseverance and their willingness to discuss the importance of preventative health care for women. also, i want to thank senator shaheen, senator murray, senator gillibrand joined by senators

harkin, cardin, dodd, and others to really come to the floor and help women with this battle. the fact is that women have different health needs than men, and these needs often generate additional costs. women of child-bearing age spend 68% more in out-of-pocket health care costs than men. most people don't know that, but it's actually true. and so we believe that all women, all women should have access to the same affordable preventative health care services as women who serve in congress, no question. the amendment offered by senator mikulski -- and she is a champion for us -- will ensure that that is, in fact, the case. it will require insurance plans to cover at no cost basic preventative services and screenings for women. this may include mammograms, pap

smears, family planning, screenings to develop -- to detect postpartum depression, and other annual women's health screenings. in other words, the amendment increases access to the basic services that are a part of every woman's health care needs at some point in her life. now, let me address one point, because there is a side by side amendment submitted by the senator from alaska. nothing in our bill would address abortion coverage. abortion has never been defined as a preventative service. the amendment could expand access to family planning services, the type of care that women need to avoid abortions in the first place. as i mentioned, the senator from alaska has offered an alternative version of this

proposal, but regardless of the merits or problems with her proposal, it remains a kind of budget buster. according to the c.b.o., the amendment would cost cost $30.6 billion over ten years. adopting this amendment would require us to spend some of the surplus raised by the class act or some of the off-budget surpluses in the bill. the underlying bill as written reduces the budget deficit by by $130 billion in the first ten years, and as much as as $650 billion in the second ten years. this is a very important thing in my view, and we need to maintain these savings. the mikulski amendment would not do that. it costs $940 million over ten years, as opposed to the the $24 billion to $30 billion in the murkowski amendment.

the mikulski amendment i believe is the best way to expand access to preventive care for women while keeping this bill fiscally responsible. we often like to think of the united states as a world leader in health care, with the best and the most efficient system. but the facts, madam president, actually do not bear this out. the united states spends more per capita on health care than other industrialized nations, but, in fact, has worse results. according to the come commonweah fund, the united states ranks 15th in avoidable mortality. that means avoidable death. this analysis measures how many people in each country survive a potentially fatal yet treatable medical condition. the united states lags behind france, japan, spain, sweden,

italy, australia, canada, and several other nations. and according to the world health organization, the united states ranks 24th in the world in healthy life expectancy. this term measures how many years a person can expect to live at full health, robust health. the united states again trails japan, australia, france, sweden, and many other countries. these statistics show that we're not spending our health care resources wisely. the system is failing to identify and treat people with conditions early on that can be controlled. part of the answer without question is expanding coverage. too many americans cannot afford basic health care because they lack basic health insurance. but another piece of the puzzle is ensuring this coverage

provides affordable access to preventive care. the ability to be screened ear early, and that's what the mikulski amendment will accomplish. women need preventive care, screenings and tests that potentially -- that potentially serious or fatal illnesses can be found early and treated effectively. we all know individuals who have benefited from this type of ca care. a mammogram that suddenly identifies an early cancer, before did has spread, before it has metastasized. a pap smear that finds precancerous cells that can be removed before they progress to cancer and cause serious health problems. cholesterol testing or blood pressure reading that suggests a person might have cardiovascular disease which can be controlled

with medication or lifestyle changes. this is how health care should work, a problem found early and addressed early. and the mikulski amendment will give women more access to this type of preventive care. statistics about life expectancy and avoidable mortality can make it easy to forget that we're talking about real patients and real people who die too young because they lack access to health care. physicians for reproductive choice and health shared the following story which comes from dr. william lininger in california. and here's what he says, "in my last year of residency, i cared for a mother of two who had been treated for cervical cancer when she was 23. at that time, she was covered by her husband's insurance, but it

was an abusive relationship and she lost her health insurance when they divorced. for the next five years, she had no health insurance and never received followup care, which would have revealed that her cancer had returned. she eventually remarried and regained health insurance, but by the time she came back to see me," dr. levinger says, "her cancer had spread. she had two children from her previous marriage and her driving motivation during her last rounds of paliative care was to survive long enough to ensure that her abusive exhusband wouldn't gain custody of her children after her death. she succeeded but she was 28 years old when she died." cases like these explain why the united states trails behind much of the industrialized world in life expectancy. for this woman, divorce meant

the loss of her health coverage, which meant she could not afford follow-up care to address her cancer, a type of cancer that is often curable if found early. and that's where prevention comes in. so this tragic story illustrates the need to improve our system so women can still afford health insurance after they divorce or lose their jobs. and it shows why health reform must adequately cover all the preventive services that women need to stay healthy. the mikulski amendment is a fight -- i'm surprised that it's a fight -- but it will help expand access to preventive care while keeping the bill fiscally responsible. to me, it's a no-brainer. if you can prevent illness, you should. it in itself will end up being cost saving. so i have a very difficult time

understanding why the other side of the aisle won't accept a measure that is more fiscally responsible by far than their measure, will do the job and will give women preventive care and begin to change that statistic, which shows that among other nations, w we do so badly. i really hope, and i thank you, madam president, for coming to the floor and speaking out on this. i really hope that there are enough people in this body that recognize that virtually everything women have gotten in history has been the product of a fight, and this is one of those. thank you, and i yield the floor. the presiding officer: the senator from new hampshire. mr. gregg: i'd ask unanimous consent that the next republican speaker be the senator from louisiana, senator vitter. the presiding officer: without objection. mr. gregg: madam president, i

wanted to rise to speak generally about the bill and specifically about this medicare proposal, the proposal from -- in the bill and the amendment that has been offered by senator mccain which i think is an excellent amendment. let's start at the size of this bill. it is unusual that we would be considering a bill of this size and not have had more time to take a look at it, but the bill itself -- and i'm glad that the chairman of the finance committee is essential -- has essentially agreed with this earlier today -- costs $2.5 trillion when it's fully implemented. $2.5 trillion. now, when my staff took a look at this bill and we only had a brief time to do it, obviously, last week and came up with that number, my budget staff, people said, on the other side of the aisle, regrettably, no, that's a bogus number. the number is $840 billion. it's not a $2.5 trillion bill. however, it is $2.5 trillion. when it's fully implemented, when the prom mat i can activity

of this bill -- programmatic activity of this bill is over full steam over this ten-year period, it will cost $2.5 trillion. that's huge. huge. now, the senator in an early quer colloquy that i heard -- earlier colloquy that i heard, the chairman of the finance committee, who does such a good job as chairman, made the point, well, it's fully paid for, it's fully paid for in each ten-year period. that is true literally. i give him credit for that. but when -- two questions are raised by that fact. the first is this: why would you expand the federal government by $2.5 trillion when we can't afford the government that we have? the resources that are being used to pay for this, should they ever come to fruition, are resources which should probably be used either to make medicare solvent, or more solvent, or, alternatively, to reduce our deficit and our debt situation as we confront it as a nation. we know for a fact that every year for the next ten years, even before this bill is put in

place, that we're going to run a trillion-dollar deficit every year because that's what president obama has suggested. we know for a fact that our public debt is going to go from 35% of our gross national product up to 80% of our gross national product within the next six years without this bill being passed. we know that we are in a position where we're head down a road -- headed down a road which is basically going to hand to our children a nation that's insolvent, fiscally insolvent because of the amount of debt that's been put on their back by our generation through spending and not paying for it. so why would we increase the government now by another $2.5 trillion when we can't afford the government we have? that's the question i think we have to ask ourselves. isn't there a better way to try to address the issue of health care reform without this massive expansion of a new entitlement, creating a brand-new entitlement which is going to cost such an extraordinary amount of money and dramatically expanding

medicaid? that's where most of the money comes -- spending comes in this bill, a dramatic expansion in medicaid, a massive new entitlement created that we don't have today th -- have tod. this bill, when it is fully implemented, will take the size of the government, which historically has been since -- in the post-world war ii period, the size of our government, the federal government, has been about 20% of g.d.p., a little less, in fact. this bill when it's fully implemented will take the size of government up to about 24% to 25% of g.d.p. well, to accomplish that and claim that you're not going to increase the deficit requires i think a real leap of faith because it means to pay for this -- and this is why the mccain amendment is so important -- you're going to have to reduce medicare spending by a trillion dollars when this bill is fully implemented. a trillion dollars over a ten-year window. in fact, during the frerd

2010 -- period from 2010 to 20 -- let me check i and make sure i've got this right -- 2010 to 2029, medicare spending will be reduced in this bill by $3 trillion. and those dollars will not be used to make medicare more solvent because we know we've got serious problems with medicare. those dollars will be used to create a brand-new entitlement and to dramatically size -- increase the size of government for people who do not pay into the hospital insurance fund, for people who have not paid medicaid -- medicare taxes, in the most part, but rather for a whole new population, people going under expanded medicaid and people getting this new entitlement under the public plan. so seniors' dollars, which were supposed to be used if they're going to be -- if you're going to reduce medicare spending by a -- in the first five years,

$450 billion, in the second -- in the first ten years, $450 billion, in the second ten years fully implemented -- there's some overlap there -- bull fully implemented, a trillion dollars, and then over a 19-year period, the two decades, by $3 trillion, instead of using those moneys, those seniors' dollars to try to make medicare more solvent, they're going to be used for the purposes of expanding and creating a new entitlement and expanding medicaid. this is hard to accept as either being fair to our senior population or being good policy from a fiscal standpoint. why is that? well, because if we look at the medicare situation, we know that medicare as it is structured today has an unfunded liability of $55 trillion. $55 trillion. that means in the medicare system, we do not know how we're going to pay $55 trillion worth

of benefits that we know we're now obligated for. now, the answer that we get from the other side of the aisle is, well, this $55 trillion number goes down because this bill cuts medicare. and, therefore, the benefit structure reduces. but the revenues or the reduction in that go to the purposes of making medicare more solvent? no. those moneys are taken and spe spent. those moneys are taken and created to -- used to create a larger government. they aren't used to reduce the deficit. they aren't used to reduce the debt, all of which is being driven in large part by this $55 trillion of unfunded liability as we go forward. no, they're being used to create a brand-new entitlement which has nothing to do with seniors and a brand-new entitlement which will be paid for in large part by seniors or by a restructure in their benefits.

that makes little sense. essentially you're taking money out of the medicare system and uses it to expand the government when, in fact, what we should be doing is if you're going to take money out of the medicare system, you should be using to reduce the obligations of the government, it's debt obligations so that the medicare system becomes more affordable. not the goal here, however. and then, of course, there's just the practical aspects of this. we know that these types of proposals are really plug numbers to a great degree. because we know that this congress is not going to stand up to a half a trillion dollar cut in medicare over the next 10 years and a $3 trillion cut in medicare over the next 20 years. why do we know that? well, i know it from personal experience. i was chairman of the budget committee the last time we tried to address the fact that we have

an out-year liability in medicare that's not affordable. this $50 trillion number. we know it's not affordable. i suggested when i was chairman of the budget committee, that we reduce medicare spending, or its rate of growth, not actual spending, its rate of growth by $5 billion over a 10-year period. less than 1% of medicare spending. my suggestion was that we do that by requiring primarily -- we got most of that money by requiring senior citizens who are wealthy to pay a reasonable proportion of their part-d premium and then take those moneys and basically try to make medicare a little more solvent with them. we got no votes from the other side of the aisle. none. zero. on that proposal. now they come forward with a representation, a representation that they're going to reduce medicare spending and benefits to seniors by $3 trillion over

the next 20 years an and $400-some-odd billion over the next 10 years. and they expect us to be taken seriously? of course not. this is all going to end up being unpaid for expenditures and expansion of these programs. these new programs, these brand-new entitlements being put in this bill and this expansion of other entitlements that don't deal with medicare, by the way, are going to end up being, in large part, paid for by creating more debt and passing it on to our children. and, as i mentioned earlier, that's a fairly big problem for our kids. they're going to get a country, as it is today -- as it is today that has about $70 trillion of unfunded liability just in the medicare and medicaid accounts to say nothing of the other deficits that we're running up around here. and now we're going to throw

another huge amount on their back -- some percentage of it is $2.5 trillion. probably a majority of it will end up being added to the deficit and debt as we move out in outer year even though it's represented that it isn't going to be. mine, the only way you can claim that you're going to pay for this, of course, is with these medicare taxes -- medicare cuts and these tax increases in this bill and these fee increases. we will spend a little time on the tax increases and fee increases, but right now we're focusing on the medicare. in any event, you have a bill that takes the government that eexplodes its size. it's already 20% of our economy. you're exploding it to 20% of the economy. you say you're going to pay for that by reducing dramatically medicare spending? well, it doesn't make any

philosophical sense and it certainly isn't going to -- it certainly doesn't pass the test of what happens around here politically. in addition there's the issue of how this bill got to a score in the first 10 years that made it look like it was more fiscally responsible. you know, i've heard people from the other side -- and, again, i respect the chairman of the finance committee for acknowledging that this bill when fully plimentd is a $2.00 -- implemented is a $2.5 trillion bill. a lot of folks claim that it is a $483 billion bill. that's all it is. in the first 10 years, that's all it costs. well, there are so many major budget gimmicks in this bill that accomplish that score, that bernie madoff would be embarrassed. embarrassed by what this bill does in the area of gamesmanship.

let's start with the fact that it begins most of the fees -- most of the taxes and most of the medicare cuts in the first year of the 10 years, but it doesn't begin the spending on the new program, the new entitlements until the fourth and fifth year. and it -- and so they're matching four and five years of spending against 10 years of income and medicare cuts and claiming that, therefore, there's a balance. ironically it is represented and rumored, and i admit that this is a rumor, that originally they were going to start the spending in the third year under this bill. of course, nobody knew what the bill was because it was written in private an nobody had got to see it. but then they got a score from c.b.o. that said, well, it didn't work that way. so they moved it back a year, spending back a year, started it

in the fourth year. the c.b.o. said if you take a year of spending out and have got the 10 years of spending from the taxes and fees and the cuts in may well, you get a better score. you'll get closer to balance. pretty outrageous little game of -- of hide the -- hide the -- you know, hide the pea under the shell. but it is probably the single biggest, in my experience, and i've been on the budget committee for quite a while, in my experience it is the single biggest gaming of the budget system i have seen around here ever. but it's not the only one. there's something else in here called the class act. i'd be happy to yield purposes of a question to the senator. mr. hatch: what is our current cost of health care across the board in this country? mr. gregg: excuse me? mr. hatch: what is the current cost of our health care in this country without this bill? mr. gregg: it's about 16% to 17%

of the gross national product. mr. hatch: you say they're going to add if you extrapolate it out over 10 years anothe another $2.5 trillion? mr. gregg: the senator from utah is correct, it will take the spending from 16% to 17% up to 20% of g.d.p. mr. hatch: if i understand correctly, you say to reach this outlandish figure o of $843 billion, that literally they don't implement the program until 2014, and even beyond that to a degree, but they do implement the tax increases? mr. gregg: the senator from utah, being a senior member of the finance committee, is very familiar with those numbers is absolutely correct. mr. hatch: is that one of the budget gimmicks that you're talkintalking about? mr. gregg: that's the biggest in the context of what it generates in the way of puric, nonexistent savings because it basically says that we're really not

spending because it doesn't fully implement the plan in the first year. it says we're not really spending that much money, when, in fact, we know when the plan's fully implemented it's a $2.5 trillion bill, not a an $840 billion bill. mr. hatch: am i correct that democrats are saying on the other side and they seem to be unified on this bill, that, literally, this bill is budget neutral. but, as i understand it, in order to get to the budget neutrality, they are socking it to a program that is $38 trillion -- about $38 trillion in unfunded liability called medicare to the tune of almost $500 billion or a half trillion dollars in order to pay for this. am i correct on that? and, number two, who -- who's going to lose out? when they start taking $500 billion out of medicare and what are they going to did with that $500 billion?

are they putting it in something else or are they using this for a budgetary gimmick? what is happening here? you were the former member of the budget committee and ranking member today. i think it would help all of us to understand this better. mr. gregg: if i can could answer the senator from utah's question and i would be happy to answer your question. the senator from utah is correct in his assumption. essentially they're claiming a 5 -- $400-some-odd billion in medicare which they -- over 10 years, which they are tiewtion finance the spending in this bill over the last five years and -- five to six years of the 10-year window. in the end, after you fully implemented this bill, and you fully implemented the medicare cuts, it represents $3 trillion

of medicare reductions over a 20-year period. where does it come from? it comes from two different accounts primarily. one is -- just about anybody who's on medicare advantage today, about 25% of those people will probably completely lose their medicare advantage insurance, which is 12,000 people in new hampshire. so -- mr. hatch: how many people in medicare are in medicare advantage? mr. gregg: i believe 11 million people. mr. hatch: that would be what percentage of people in medicare? mr. gregg: about 5%, mostly in rural areas. and, secondly, because there' there's $160 billion of savings scored. now, you can't save that type of money in medicare unless people -- medicare advantage, unless they don't get the medicare advantage. and, secondly, it comes in significant reductions in provider payments. how do provider payments get paid for when they're cut? i would ask the senator from

utah, but i suspect it's because less health care is provided. mr. hatch: how does that affect the doctors? mr. gregg: i suspect it certainly affects the doctors and it will probably affect the doctors. i've heard the senator from montana say they're going to straighten out the doctor problem down the road here. but that's another $200 billion or $350 billion of spending which we don't know where they're going to get the money from. it would affect all providers, doctors, hospitals, and other people who provide health care to seniors. and -- because you can't tak take $450 billion out of the medicare system and not affect people's medicare. mr. hatch: am i wrong in saying that the medicare -- that medicare already is headed toward insolvency and that it has up to and almost $38 trillion in unfunded liability over the years for our young people to have to pay for?

mr. gregg: the senator from utah is correct again. the medicare system is headed toward insolvency and it goes cash negative in 2013, i believe, maybe it's 2012, in the sense that it's paying out less than it takes in. and it has a -- an unfunded liability that exceeds actually $38 trillion now. mr. hatch: how can our friends on the other side take a half trillion dollars out of medicare that's headed towards insolvency to use for some of the programs that they want to now institute as anew? mr. gregg: i think that the senator from utah asked one of the core questions about this bill. why would you use medicare savings, reductions in medicare benefits, which well definitely affect recipients for the purposes of preating a new program rather -- creating a new program rather than making

medicare more solve yent and if -- solve yent, and if you're going to do that in the first place. and are these savings really going to come about? one wund rs about that also. mr. hatch: someone said today, i can't remember who on the floor, said that medicare advantage isn't really part of medicare. is that true? mr. gregg: i would yield to the senator from utah on that issue, not the floor, because the senator from utah was there when medicare advantage was drafted as a law. mr. hatch: i was on the medicare modernization conference, along with the distinguished chairman of the committee, senator baucus and others, when we did that because we were not getting health care to rural america. the medicare choice plan didn't work. doctors wouldn't take patients. hospitals couldn't pay -- couldn't take patients. there were all kinds of difficulties in rural america. so we did medicare advantage and all of a sudden we were able to take care of those people.

yes, it cost more, but it's because we had to go into the rural areas to do it. this would disseminate medicare advantage what's proposed here? and that is part of medicare. mr. gregg: it is, i believe, a legal part of medicare. mr. hatch: no question about it. mr. gregg: this would, in my opinion have a massively disruptive effect on people who get medicare because you're going to reduce it, the assumption, the scoring is that there will be a reduction in medicare advantage payments of approximately $162 billion, i believe it is, and there's no way you're going to keep getting medicare -- the advantages of medicare advantage if you have that type of reduction in payments. mr. hatch: how can they take a half trillion dollars out of medicare? and that's not all medicare advantage. medicare advantage is only part of that, the deductions that they'll make there. but how can they do that and still run medicare on a solvent, constructive, decent and honorable fashion?

mr. gregg: well, the problem is medicare -- if the senator will allow me to respond? the problem here is that we have rolled the medicare issue into this major health reform bill, or the other side has, and they have used medicare as a piggy bank for the purposes of trying to create a brand-new entitlement which has nothing to do with senior citizens. and yes, medicare needs to be addressed. it needs to be reformed. and the benefit structure probably has to be reformed, but we shouldn't use those dollars for the purposes of expanding the government with a brand-new entitlement. we should use those dollars to try to shore up medicare so that we don't have this massive insolvency. mr. hatch: you mean they are not using this $500 billion to shore up medicare and help it during its period of possible insolvency with this this $38 trillion unfunded liability? they're not using it for that purpose? mr. gregg: that is correct. mr. hatch: what purpose are they using it for? mr. gregg: well, they are using

it to fund the underlying bill and the underlying bill expands a variety of different initiatives in the area of medicaid and in the area, of course, of the brand-new entitlement for people who are uninsured. mr. hatch: you were going to talk about the class act that's in this bill. mr. gregg: the class act is another classic gimmick of budgetary shenanigans which i would like to speak to briefly but i know the senator from montana had a question, or maybe we have gone past that point and we have answered all his questions. mr. baucus: to be honest, i would frankly like to hear you talk about the class act because frankly i am no fan of the class act myself, so you can proceed. mr. gregg: i thank the senator from montana for his forthrightness on that, because the class act needs to be explained. it's a great title. what we do around here is amazing. we come up with these wonderful motherhood of titles. they suddenly take on a persona that has no relationship to what they actually do. the class act is a long-term

care insurance program which will be government run. it's another takeover of a private sector activity by the federal government. but what's extraordinarily irresponsible in this bill is that we all know in long-term care insurance that you buy it when you're in your 30's and your 40's. you probably don't buy it when you're in your 20's. you're probably not worried about it then. you buy it in your 30's, your 40's, and your 50's, so you start paying in premiums then, but you don't take the benefits, the costs of those insurance products don't incur to the insurer until people actually go into the retirement home situation, which is in their 60's, late 60's, 70's, most likely, most likely 80's in our culture today with many people working well into their 70's. so there is a large period of people paying in, and then ten -- 30 or 40 years later, they start to take out. well, what's happened in this

bill -- which is so -- it's just a classic ponzi scheme. in fact, ironically the chairman of the budget committee did call it a ponzi scheme, the senator from north dakota, senator conrad. they are scoring these years when people are paying into this new program, and because the program doesn't exist, everybody who pays into it starting with day one benefits -- the beneficiaries of that program aren't going to occur until probably 30 or 40 years later. they're taking all the money that's going to be paid in when people are in their 30's, 40's, 50's, 60's as premiums, they're taking that money and they're scoring it as revenue under this bill, and they're spending it on other programmatic initiatives for the purposes of claiming that the bill is balanced. it adds up to about $212 billion over that 20-year period,

2010-2029. well, okay, so you spend all this -- all the premium money. what happens when these people do go into the nursing home? do require long-term care when they become 75, 80, 90 years old? there's no money. it's been spent. it's been spent on something else. on a new entitlement, on expanding care to people under medicaid, on whatever the bill has in it. and so we're going to have this huge bill that's going to come due to our kids one more time. we're already sticking them with -- we have $12 trillion of debt right now, and we're going to raise the debt ceiling sometime in the next month to -- i don't know what it's going to be. i have heard rumors that it may be as high as $13 trillion or more. we know that we have got another another $9 trillion of debt coming at us just by the budgets

that have been projected for the next ten years, and now you're going to 30 years from now have this huge bill come in as the people who decided to buy into the class act suddenly go into the retirement home. and there won't be any money there for them. it's gone. it will have been spent by prior generations to make this bill look -- so the class act is, as has been described, a ponzi scheme relative to its effect on the budget. it's using dollars which should be segregated and protected under an insurance program. if this were an insurance company, for example, they would have to actually have to invest those dollars in something that would be an asset which would be available to pay for the person when they go in the nursing home so that they are actuarially sound, but that's not what happens under this bill. under this bill, those dollars go out the door as soon as they come in for the purposes of

representing that the -- that this bill is in fiscal balance, and it's not. it's not in fiscal balance, obviously, but even if you were to accept these really incredible activities of budgetary gimmickry, the fundamental problem with this bill is it grows the government by $2.5 trillion, and we can't afford that when we already have a government that well he can seeds our capacity to pay for it. inevitably, we pass on to these young pages here as they go into their earning careers and raise their families a government that is so expensive that they will be unable to buy their home, send their kids to college or do the things they wish to do that give you a quality of life. well, i've certainly taken more than my fair share of time here at this point, and i think the senator from louisiana was going to go next. oh, i'm sorry. i yield the floor.

mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: mr. president, it has been somewhat -- it's been a very listening discussion listening to the senator from new hampshire. several points here. one, this is -- the underlying bill is clearly not a net increase in government spending and health care. the numbers are bandied about by those on this side, one trillion, two and a half trillion, et cetera. i do acknowledge and thank the senator from new hampshire for saying yes, that is all paid for. he did say that and he did agree that this is all paid for, so i just hope when other senators on that side of the aisle start talking about the big cost, one trillion, two trillion, whatever, that they do admit it's paid for. the ranking member of the budget committee flatly said yes, it is

all paid for, and i would hope that other members on that side of the aisle heed the statement of the senator from new hampshire, the ranking member of the senate budget committee saying it's all paid for. but don't take my word for it either or his word for it. it's what the congressional budget office says. in fact, let me quote from a letter to senator reid not too long ago." the c.b.o. expects that during the decade following the ten-year budget window, the increases and decreases in federal budgetary commitment to health care stemming from this legislation would roughly balance out so there would be no significant change in that commitment." that is a commitment to health care -- to government health care spending. no change basically. it's flat. although it's a little better than flat because the subsequent c.b.o. letter has said that -- that the underlying bill achieves about $130 billion in deficit reduction over ten

years, and then .25% of g.d.p. reduction in the next ten years. now, i -- the senator from new hampshire talks about large deficits this country is facing. that is true. we clearly as a country -- frankly, all of us here in the senate have a responsibility to try to reduce that budget deficit as best and as reasonably as we possibly can. but i remind my colleagues that this underlying health care bill helps reduce the budget deficit. there's a -- sometimes people on that side like to suggest that $1 trillion over ten years will add to the budget deficit. again, we've definitely established that it does not add to the budget deficit at all, not one thin dime. but in addition, we actually do reduce the budget deficit through health care -- through this underlying legislation. we all know that the medicare trust fund is in jeopardy, in

part because baby boomers are retiring more, but also because of health care costs are going up at such a rapid rate in our country. that's health care costs for everybody. it's health care costs for me. it's health care costs for every senator. it's health care costs for every senior. it's health care costs for businesses. let's not forget, mr. president, we spend in america about 50% or 60% more per person on health care than the next most expensive country. about 50% to 60% more per person than the next most expensive country, and the trend is going the wrong direction. we're going to spend about about $33 trillion in america on health care over the next ten years. $33 trillion just on health care, and that's going to be somewhat evenly divided between public expenditures and private expenditures. i'm not -- every other country in the world has figured out ways to limit the rate of growth of increase in health care

spending. we haven't. we're the only industrialized country. in fact, developing country that hasn't figured out how to get some handle on the rate of growth of increase in health care spending. now, one could say well, gee, let's forget about it. let's let this present trend continue. we all bandied about different figures. one i'm kind of fond of at least remembering is that the average health care insurance policy in america today costs about about $13,000, and if we do nothing over eight years, it's going to be $30,000. now, that's much, much higher rate of increase than wages, income for americans, which just means the disparity between wages of the average americans and what they're paying on health care widens, widens, widens all the more if we do nothing. so we have to do something, and this legislation is a good-faith effort to begin to get a handle on the rate of growth of spending in this country.

now, the senator from new hampshire points out that gee, he kind of implies that -- no, he is being honest about it, frankly. some on the other side are being not quite so honest. he's basically saying yes, it is true that -- that we're not cutting beneficiary cuts, although he talks about medicare advantage. and let me just at that point point out that there's nothing in this legislation that requires any reductions in any beneficiary cuts. in fact, guaranteed benefits under medicare are expressly not to be cut under the express language of this bill. the part and portion we're talking about is medicare advantage, and the fact is there's nothing in this bill that requires any cuts at all in medicare advantage payments. those medicare advantage payments are in addition to the guaranteed medicare payments.

you know, like gym memberships and things like that which is not part of traditional medicare. why do i say there's nothing in there that requires cuts for those extras? it's not medicare, but those extras? that's because the decision on what -- quote -- benefits or what extras medicare advantage plans have to give the guaranteed benefits, that's by law, but the decision as to what extras should go to their members is a decision based not upon us and the government or the congress, not upon h.h.s. secretary, it's based upon the corporate officers of these companies. now, how are they going to -- they're overpaid, medicare advantage plans right now. everybody knows they're over paid. even they privately will tell you they're overpaid. they are paid based on legislation the congress passed in 2003, medicare part-d by saying these -- sitting these

high benchmarks. they are just overpaid. and the medpac commission also said they're overpaid to the tune of 14%, 18%. so the reductions that are provided for in this bill and medicare advantage plans, the effect of those reductions is up to the officers of those plans. they could use those -- they could cut premiums that people otherwise pay. they could cut benefits to help themselves, help their salaries. they got stockholders. they got administrative costs. they can decide what they want to do. that's solely a decision of the executives of medicare advantage plans, private insurance plans. they're private. private insurance plans. there's nothing here that says the fringes, the extras have to be cut at all. those executives could keep those fringes and maybe have a little less returned to their

stockholders or maybe make some savings in their administrative costs. maybe not increase their salaries. there's nothing here that requires those fringes, those extras to be cut. nothing whatsoever. now, the senator from new hampshire says it's about $400 billion to $500 billion of reduced payments to providers is in this legislation, and that is true. well, let's look to see what the consequences of that are. first of all, that means that the medicare trust fund is more -- solvency is extended. it's more flush with cash. and i would think that all senators here would like to extend the life of the medicare trust fund. a good way to do that is what we're doing in this bill, saving about $400 billion over ten years that otherwise would be paid to medicare providers is not being paid, those benefits in here to the trust fund.

there is no dispute, none whatsoever that this legislation extends the life of the medicare trust fund by another five years. that's because of those changes in the structure and also because there's no cuts in benefits. there are no cuts in benefits, senators, unlike sometimes i hear senators on this side of the aisle like to either say or strongly imply there are cuts in benefits, there are no cuts in benefits. there's no cuts in the guaranteed benefits with the basic benefits, and there's no required cuts for the fringes or the extras because the officers can make that decision not to cut if they want to. that's their choice, as i've just explained just a few minutes ago. well, let's look to see what the other side proposed not too many years ago. it was back in 1997. they proposed cutting the medicare benefits structure, cutting payments to providers big time. big time. they proposed a 12.4% cut to

providers back in 1997, when they were in charge. they did that in part to save the medicare trust fund, to extend the life of the medicare trust fund. i have a hard time understanding why back then it was a good thing to do, which is about three times more cut than -- twice as heavy a cut in medicare providers back then, 1997, than it is today. nobody over here can explain to me why it was the right thing to do back then when it is not the right thing to do today when the goals are the same, the goals are the same of the solvency, of the trust fund. one could say, and i think the senator from new hampshire did say, well, let's take those savings which does extend the solvency of the trust fund but not, he said, by another program. i think he wants to use that to cut the deficit. that's what i think he wants to

do. well, that's a very basic fundamental question i think this country should face. that is: do we want to set up a system where virtually all americans have health insurance or not? we're the only industrialized country in the world that does not have a system where its citizens have health insurance. only industrialized country in the world. it's a very basic question i think we should ask ourselves as americans. in every other industrialized country, health insurance, health care is a right. that's the starting point in every other country that has health insurance, a health care system, health care is a right, that everybody should have health care. of course it's true different people are different. some are tall, some are short. some are very athletically endowed, some are not.

some are smart, some are not so smart. but health care does not care, if that's the way to put it, whether you're dumb, smart, tall, skinny. it affects everybody. that is, diseases affects everybody. and everybody needs health care regardless of your stage in life, regardless of your income, regardless of whether you're an egghead, brilliant, you're an athlete. we're americans. and i frankly believe other countries on that point have it right. that is that they treat all their citizens basically equally because disease, you know, is indiscriminate. who's going to get disease. accidents are indiscriminate, who's going to get an accident, and so forth. we could take this $400 billion, $500 billion and reduce the deficit with it and forget any health insurance coverage. that would be an option. that had be an option.

that's -- that would be an option. that's a legitimate question we could ask ourselves. i frankly think the better choice is to take that $400 billion, $500 billion which does extend the solvency of the trust fund and help set up a way, help set up a system so that all americans have health insurance, and do it in a way that reduces the budget deficit, mr. president. we do it in a way that reduces the budget deficit in the first ten years and in the next ten years. and i just repeat, if trimming the rate of tkpwoegt of provider payments -- of growth of provider payments was okay back in 1997 and twice as much as today back then to extend the solvency of the medicare trust fund, why isn't it okay today to do half as much, to extend the life of the trust fund, in this

case, for five more years and at the same time provide health insurance benefits for people who deserve it? let's not forget hospitals want us to do this. they would like everyone to have health insurance. doctors want us to have a system where everybody has health insurance whr-rbgs -- whether it's medicaid or a private health insurance. all the providers want it. the pharmaceutical industry was, health insurance industry was, hospice industry does, durable medical equipment manufacturers want it. they all want it. they know it's the right thing to do because they know they're not going to get hurt. i heard some h.h.s. actuary commenting on the house bill, saying, oh, gee, it might scare providers and whatnot. we've actually got subsequent information to show, that actuary admitted it's extremely variable what he came up with,

lots of factors he had not taken into consideration. i also have statements from hospital administrators saying no way are they going to be allowed. let's remind ourselves of this. it wasn't too many weeks ago, a couple of months ago, remember that meeting? all the health care providers in the insurance industry went to the white house. they were all over there. what did they pledge to president obama to get health care reform passed? that they would cut their reimbursements by $2 trillion over ten years. they would cut. they agreed to cut their payments that uncle sam makes to them in the health care system by $2 trillion over ten years. it was widely reported in the paper. what do we do in this bill? reduce the rate of increase in payments to providers not by $2 trillion, not by $1 trillion. less than $500 billion over that same ten-year period.

if they could commit back then to $2 trillion, you'd think, my gosh, a quarter of that, if that's not too bad, it's not going to hurt anybody, providers are not going to be leaving. i might just add too this letter from aarp to the majority leader stated today. it's just been handed to me. "the legislation before the senate properly focuses on provider reimbursement reforms. most importantly, the legislation does not reduce any guaranteed medicare benefits." this is a letter from the american association of retired persons today. youi'll repeed that portion. the legislation before the senate properly focuses on provider reimbursement reforms. only about a week or so, on top of all the reforms in this bill which are so important so we have a better health care system, focusing more on quality

than we currently do in our system. again, most importantly, the legislation does not reduce any guaranteed medicare benefits. moving on, aarp believes that savings can be found in medicare through smart, targeted changes aimed at improving health care delivery, eliminating waste and efficiency and aggressively rooting out fraud and abuse. that's really important. it's very important. i might add too that every person today who pays part-b premium, every american today, every senior today who pays that 25% part-b today pays also for the waste that's in the system today, especially under part-b. we get the waste out, then we also can be able to reduce that part-b premium payment that seniors have to pay too, and i think that's a good thing too.

the more you dig into this bill, the more you see the good features. i don't think all the good features have really been pointed out in this bill. that is one of our jobs here is to point out what they are so that when this legislation passes, mark my words, this legislation is going to be enacted, it's going to be enacted within -- i won't say exactly when. but certainly if not this month, it's going to be signed by the president either this month or next month. then -- then -- americans are going to start to see, gee, there is a lot of things that are really good. that's good. i like that. it may not be perfect, but they start in the right direction. that's pretty good. i like it. i hear all these reference to the polls around here, but that's because of all the confusion. once it's passed and people look to see what's in it -- they'll look to see what's in it because that's the law. they're forced to look to see what's in it because that's the

law. colleagues say they'll look and see how bad it is. i disagree. that's not my view. my view is that more of this legislation is subjected to the light of day and shows what really is in this bill, the more people are going to say, hey, that is a good thing they did back then in december or january. i yield the floor. mr. vitter: mr. president? the presiding officer: the senator from louisiana mr. vitter: thank you, mr. president. mr. president, i rise to talk about a very important topic that's on the floor right now, and that's preventative screening and focus specifically for women. i want to focus on a particular example of that, which is breast cancer screening through mammography and also through the practice of self-examination. this is very, very timely, mr. president, because just two weeks ago a u.s. government-endorsed panel issued

new recommendations on this topic, which i believe along with tens of millions of americans is a major step in the wrong direction. and i think we need to focus on this recent action and talk about this and fix it in the context of this health care reform debate. what am i talking about? mr. president, on tuesday, november 17, literally just a couple of weeks ago, the u.s. preventive service task force, which is an official government-sanctioned body, a task force about preventive medicine, issued new recommendations regarding breast cancer screening for women, including the use of mammography. these new recommendations that came out just a couple of weeks ago are a big step backward, a big retrenchment in terms of what the current state of knowledge was and what their

previous recommendations were. their new recommendations just added two weeks ago do four things that really take a big step back on breast cancer screening. number one, for women between the ages of 40 and 49, rather than you get a routine mammogram every two years to screen for breast cancer, the task force said forget about that. we don't recommend that anymore. we step back from that recommendation. number two, for women aged 50 to 74, the previous recommendation was get a routine mammogram to screen against breast cancer every year. the task force two weeks ago stepped back from that and said, no, every other year is probably good enough. so not every year; every other year. number three, for women over the age of 75, the previous recommendation was to have

routine screening at least every two years. the new recommendation from the task force steps back from that. it says no, we don't recommend routine screening over the age of 75. and number four, the task force two weeks ago said we no longer recommend breast self-examination by women to detect lumps to get treatment early. we don't believe in that. we don't think the science is clear on that. we step back from that. those are four huge changes in their previous recommendations. those are four huge, new recommendations completely at odds with what i believe is the clear consensus in the medical community and the treatment community. now, when i first read about these new u.s. preventive service task force recommendations around november 17, i had the immediate reaction

i just -- i just enunciated. but i said, you know, i'm not an expert. i'm not a doctor. i'm not a medical expert. i want to hear from folks who are much closer to this crucial issue than me. and so my wife and i convened a round table discussion in baton rouge, louisiana. we had on monday, november 23. it was at the maryberg perkins cancer center. we had a great round table discussion featuring a lot of different people, including oncologists, other m.d.'s, other medical experts, and including -- maybe most importantly -- several breast cancer survivors who literally lived through this issue themselves. and those breast cancer survivors were all women who got breast cancer and had it detected relatively early in their 40's.

so they're exactly the group of people that these new recommendations would work against because the new recommendations say, don't get regular mammography to screen in your 40's. again, i was interested in hearing from the real experts, both the medical experts and the survivors, what they thought about it. and i wasn't very surprised, quite frankly, when they all had exactly the same reaction that i did to these new u.s. preventive service task force recommendations. everybody to a person said, this is a big step backward. this will make us move in the wrong direction, increase screening, earl -- this will mas move in the wrong direction. increased screening is a leading reason why we're winning in the fight against cancer. it's a leading reason why we're doing so much better in this fight. you know, this that one room at the maryberg perkins cancer

center, in a sense, we had a snapshot through history and proof of the great gains we've made, including through early screening, becausee because, as, we had these survivors, all a supercause for celebration, folks had had detected their cancer, most of them relatively early, all of them first got it and detected it either in their 40's or some in their 30's. and, unfortunately, in the same room we had a life experience on the other end of the spectrum going back 40-plus years. that's my wife wendy who lost her mother to breast cancer when she was six years old. and one of the reasons is simple and straightforward and directly related to what we're talking aboutabout. back in the late 1960's when wendy lost her mom to breast cancer, there wasn't the same routine. there wasn't this emphasis on

screening. this wasn't the recommendation -- there wasn't the recommendation for annual mammograms. there wasn't the educational push for self-examination. there wasn't that focus. and because of that, far more women tragically including wendy's mother, died. well, we've made huge progress since then. again, the very life experiences in that one room in baton rouge proved that, and the medical doctors and the oncologists, the other experts, as well as the breast cancer survivors, all made that point. so i'm standing on the floor to urge us to take focused specific action to legislatively repeal any impact of these new recommendations by the u.s. preventive services task force issued in november. now, this topic is on the floor. it's on the floor through the

mikulski amendment. therthere is probably going to a republican alternative to that mikulski amendment. my concern is that in terms of everything on the floor now, none of it directly, specifically takes back the impact of those new recommendations. and i think that's the first thing we should all come together on 100-0 on this topic. we can have a broader debate. we can have differences about the best approach to prevention and screening. but the first concrete, focused thing we should do right now on the floor today is come together 100-0 to legislatively overrule any impact of those new recommendations. that's, again, what i've been hearing from experts -- not just in baton rouge, not just in that one room but across the country, experts in terms of ol oncologi,

other leading doctors, and perhaps most importantly, breast cancer survivors. i dare say, that's what every member of this body has heard from their states since those new recommendations came out around november 17. so, again, whatever we do in this broader debate, i have a very simple, basic, focused suggestion: let's show the american people we can come together around something i believe we all agree on. there is an expression, "it's mom and apple buy." well, this should be considered mom and apple pie because it's literally about mom and our wives and our daughters and, obviously, half the population. so let's come together around this issue and let's

legislatively overrule any legal impact, any legal consequence of these new task force recommendations of the u.s. preventive service task force. that's what my vitter amendment number 2808 does. i had hoped that the amendments on the floor on this general topic would do that already. unfortunately, the one that's pending now - at least -- the mikulski amendment -- does not do that. in fact, in some ways it points to the new recommendations of the task force and holds up those new recommendations. current law holds up the current recommendations. i think, because the new recommendations they promulgated around november 17 are so egregious, such a bad idea, because the consensus around the country, starting with experts, onologists, is so clear, that we should negate any impact on

them. and so, again, my vitter amendment 2808, which is currently filed as a second-degree amendment to the mikulski amendment, would do that. let me just be perfectly clear and read my text because it's very short. quote -- "for the purposes of this act and for the purposes of any other provision of law, the current recommendations of the united states preventive service task force regarding breast cancer screening, mom ma mammogy and prevention should be considered the most current of those issued around november 2009." it says, we are canceling out any effect of those new recommendations made by the task force in and around november 2009. we are saying that never happened because the consensus

is so clear against it. again, i expected the mikulski amendment to do that directly. it doesn't do that. it does other things about prevention, which is fine. we can debate those points. we can have a discussion about that. but i think we need to all come together to absolutely categorically specifically legislatively take back, overrule, these new recommendations. i'm certainly eager to work with everyone in this body, starting with senator mikulski, starting with senator murkowski, who i believe may offer a republican alternative, to include this language. i would hope that this language, which seems to me is a no-brainer, given the consensus on the topic -- that this language can be included in both those amendments. it should be just accepted and included in the mikulski amendment. it should be accepted and included in the murkowski amendment. that would be my goal so that

whatever happens on these votes, we come together in a unified way, literally. it would in he sense be 100 -- it would be in essence 100-0, no, timeout. these new recommend dailingses of the u.s. prevent -- these new recommendations of the u.s. preventive services task force of november of this year are a huge step backwards, a huge mistake. those what experts are saying, that's what oncologists are saying, that's what cancer specialists are saying, that's what leaders of cancer associations are saying, that's what, perhaps most importantly, breast cancer survivors are saying. and we can look at history in this country in the last several decades happily point to real progress in this fight, and one of the causes of that good news, that improvement, since the late-1960's when my wife wendy's

mom passed away from breast cancer, clearly one of the underlying reasons, one of the leading causes is dramatic improvement in this prevention and screening, using mammogram, also educating about self-examination. so, again, mr. president, i have this second-degree amendment. my hope and my goal would be that this language, which should be noncontroversial, would be accepted on it as well as any republican alternative, and that whatever happens in terms of those votes we come together and make crystal clear that that task force -- unelected bureaucrats, didn't include a single oncologist by the way, made a big mistake and we're going to make sure those new recommendations don't have any impact in terms of law, in terms of government programs, in terms of legal impact on insurance

companies. mr. president, again, i look forward to working with everyone on the floor, including senator mikulski, including senator murkowski and others, to pass this language. it should be a no-brainer. it is mom and apple pie. let's pass it and at least in this focused way come together and dot right thing in direct reaction to -- and do the right thing in direct reaction to something that happened a few weeks ago. thank you, mr. president. i yield the floor. mr. brown: mr. president? the presiding officer: the senator from ohio is recognized. mr. brown: thank you. i certain appreciate senator vitter's empathy for victims of breast cancer, for people who obviously should be tested for breast cancer, in many cases more frequently than they are. i'm sorry about wendy's mother's death from breast cancer. i think, though, mr. president, that senator vitter missed the larger point here. while most of news this chamber

disagree with the finding of that bush-appointed commission -- committee, commission, task force, i think that the bigger question is that a whole lot of the status quo, which senator vitter has defended, sort of ad hominem, the bigger question is under the status quo, so many women aren't getting tested for breast cancer. it's estimated 4,000 breast cancer deaths could be prevented just by increasing the percentage of women who receive breast cancer screenings. that's why the mikulski amendment is so important. it's important because in this country today, if you take a group of 1,000 women who have breast cancer who have insurance and 1,000 women who have breast cancer who don't have insurance, those who don't have insurance are 40% more likely to die. so that the issue here is that

committee -- i think that commission made a mistake. i think most of us here think that commission made a mistake. i'm not sure why those people that president bush put on the commission made that decision. but the larger point is that women without insurance don't get tested. women without insurance are 40% more likely to die if they have breast cancer than those if they have insurance. in the state of maryland, women typically pay more for insurance than men do, on the average. so if we're going to do this right, it meanings that we need insurance re-- it means that we need insurance reform, which is what this legislation does. no more preexisting condition. no more men and women who have their insurance canceled because they got too sick last year and had too many expenses and the insurance companies practiced rescission, they cut them off. no more if i have insurance and i have a child born with a preexisting condition do i lose

my insurance. mr. president, i come to the floor pretty much every day reading letters from people in ohio, fro from galian and lima,l over my state. typically, people are pretty happy with their insurance. if they had written me a yearling, these people. but today these people writing are -- found out their insurance really doesn't cover what they thought it did. they end up lees losing their insurance because of a preexisting condition. they can't get insurance because they once had breast cancer. they've had discrimination against them because of gender or geography or disability. that's what's important about the bill and what's important about their -- the mikulski amendment. that's why i would hope senator vitter, as he's pushing for assistance for women with breast cancer -- i applaud him for that -- he would go deeper than just dismissing the recommendations of one government commission. that in fact he would advocate for better testing, more frequent testing for women that

are not getting tested today and that the rates for women would be comparable to the rates for men. that's again why the mikulski amendment is so important. again, i'll repeat, the health reform legislation will -- as is will finally end gender discrimination, discrimination that charges women significantly higher premiums because they've had children. it's considered a preexisting condition by some insurance companies if a woman had a c-section, because one, she might get pregnant again and if she does, she's going to have to have another c-section and that costs more. so a woman with c-section has a preexisting condition. a woman month has been in some cases -- a woman who has been in some cases, in some insurance companies, a woman who has been victimized by domestic violence has -- has a preexisting condition because you know what? the boyfriend or the husband or whomever, whoever hit her the one time, the insurance companies would suggest, are going to do it again. so she has a preexisting

condition. what kind of health care system is that? that's -- that's why i -- i suggest, senator vitter, support the mikulski amendment and senator vitter support this legislation because, in fact, it will put rules -- it will put rules on insurance policies so that people will be treated in a different way than they have in the past. let me talk for a moment -- just for a couple of moments, mr. president, about -- specifically about the mikulski amendment, why it's -- why it's so important. you know, it will ensure that women are able to access needed preventive care and screenings at no additional cost. one of the things, in spite of my friends on the other side of the aisle on the mccain amendment -- i appreciated senator baucus' comments a minute ago, about how ironic it is. i've been in the house of representatives for 14 years, now the senate for the last three or so, how -- i have heard so many of my colleagues just eviscerate medicare. they've tried -- they've tried to cut medicare, privatize medicare from all different directions repeatedly over these 15 years. now they want to tell us they're the saviors of medicare, they're

the ones that want to protect medicare when, in fact, this legislation saves money, this legislation saves lives, and this legislation saves medicare. so, this -- this legislation will require, and one of the things this legislation does for medicare beneficiaries is it will begin to provide these preventive screenings, preventive care and screenings at no -- so the snrrs pay no co-- seniors will pay no co-pay. that's another benefit this legislation provides. it's not cutting medicare and services, as my friends on otter side of the aisle, all who ar are -- friends on the other side of the aisle, all who are opposed to this legislation. we can't even vote on the mccain amendment. we can't even get a vote because the republicans don't seem to want to move forward on this legislation. but again, let's go back to why the mikulski amendment makes so much sense. all health care plans would cover comprehensive women's preventive care and screening, requiring that these recommended services be -- be covered at no cost to women. and that's -- you know, we know

to get preventive screenings and care, that if we -- if we make them at no cost, the chances of people getting them are significantly higher. we know that more than half of women delay or avoid preventive care because of those costs associated with these services. one in five women aged 50 has not received a mammogram in the past two years. this isn't because of this commission that made this decision, this commission appointed by -- by the former president, president bush, it's not because of their bureaucratic decision that senator vitter rails about and many of us agree with him on, it's not because of that that these women -- that one in five women aged 50 haven't received a mammogram the past two years. in most cases, it's because they don't have insurance and they can't afford to get this mammogram. so in 2009, as i said earlier, some 40,000 women will lose their lives to breast cancer. 4,000 breast cancer deaths, 1/10th of those could have been prevented just by increasing the percentage of women who receive these screenings. so under medicare and under our

legislation, this kind of preventive care, these kinds of mammograms, these kind of doctors visits will be covered for free for women that go in to get them. the amendment would broaden the comprehensive set of women's health services that health insurance companies must pay for. for instance, the amendment would ensure that women of all ages are able to receive the mammograms covered by their insurer. it would encourage coverage of pregnancy and postpartum depression screenings, pap smears, screenings for domestic violence, and annual women's health screenings. i mean, it just makes so much sense. it saves the lives -- it saves the lives of a lot of women. it would mean that a lot of women would suffer a lot less from these illnesses. it would keep intact a lot more families, and it's going to save money for the whole health care system because these women will get detected early -- their illnesses will be detected much earlier and they'll get the kind of care they should. that's what this whole legislation's all about. that's what the mikulski amendment will add too. this amendment is important for removing any and all financial barriers to preventive care so

we can diagnose those diseases in early -- diseases and illnesses earlier, when we obviously, logically have the best chance to save livesment -- lives. the -- understand again too, mr. president, this legislation, the mikulski amendment, is supported by the national partnership for women and families, the american cancer society, cancer action network, all kinds of womens organizations. they understand this is the best thing for women in this country. it's my hope the senate can proceed to a vote on this amendment, so i hope that my republican colleagues will not just talk about the bad decision of this commission, and most of us think it was a bad decision, but to actually do something about it, to do something substantive, give women in this country a fairer shake from the health insurance companies, cover these prevention -- preventive services and cancer screenings. it will make a big difference if we -- if we can move forward and expand these preventive health care services to women. thank you, mr. president. i yield the floor. mr. coburn: mr. president? the presiding officer: the senator from oklahoma. mr. coburn: thank you.

i want to pick up where my colleague, mr. brown -- senator brown left off. i want to describe one of my real patients. i won't use her name but i want to describe one of my real patients to you. i'll call hershe her -- i'll car sheila. sheila was 32 years old. sheila came in with a breast mass. examined it. i thought it was a cyst. i sent her to an ultrasound. you will ultrasound confirmed the cyst. okay? confirmed the cyst. did a mammogram to make sure. mammogram says it looks like it's just a cyst. now, the standard of care for somebody with a cyst is watch it expectantly unless it's painful because 99% of them are just benign cysts. i had the good fortune to do a

needle drainage on her cyst three days after she had her mammogram. highly malignant cells within the cyst. she has since died. the reason i want to tell the story about sheila is what the senator from ohio, in supporting the mikulski amendment, what he doesn't recognize is that we don't allow the -- the preventive services task force to set the rules and guidelines. we do something worse. we let the secretary of h.h.s. set the guidelines. and the people that ought to be setting the guidelines aren't the government. they're the professional societies that know the literature, that know the standard of care, that know the best practice.

and, in fact, the mikulski amendment doesn't mandate mammograms for women. it leaves it to hrsa, the health resources service administration, who have no guidelines on it today whatsoever. so what you're saying with the mikulski amendment is that we want the government to once again decide -- we've just -- all of us are just rejecting what the preventive services task force has said. but instead we're going to shift, we're going to poft and we'll say, we'll -- pivot, and we'll say we'll let the health resources services administration decide what your care should be. now, the other aspects of the mikulski amendment i fully agree with. i don't think there ought to be a co-pay on any preventive services. i 100% agree. but the last place we ought to be making decisions about care and process and procedures is in a government agency that, number one, is going to look at cost as

much as they're going to look at preventive effectiveness. and if the truth be known, the preventive services task force from a cost standpoint -- as a practicing physician, i know how to read what they put out -- from a cost standpoint is exactly right. from a clinical standpoint, they're exactly wrong. because if you happen to be under 50 and didn't have a screening mammogram and your cancer was missed, to you they're 100% wrong. you see, the government can't practice medicine effectively, and what we're trying to do in this bill throughout is have the government practice medicine. whether it's the comparative effectiveness panel, whether it's the medicare advisory commission. what we have asked is government to make decisions. now, wil let me tell you what tt

is. that's the government standing between me and my patient. it's denying me the ability to use my knowledge, my training, my 25 years of well-earned gray hair and combine that with family history, social history, psychological history, family history -- again where it might be important -- clinical science and me putting my hand on a patient like i did sheila. for most physicians would never have stuck a needle in that cyst and she would not have lived the 12 years that she lived. she would have lived one or two. but you got 12 years of life because clinical judgment wasn't deferred or denied by a government agency. and so i'll come back. there's a wonderful member of the british parliament. he happens to be a physician. and when we were debating the

issue of the comparative effectiveness panel, which will be applied to whatever hrsa does or the secretary does, i asked him, what about the national institute of comparative effectiveness in england. and here's what he said. he says, as a physician, it ruins my relationship with my patient. because no longer is my patient 100% my concern. now my patient's 80% my concern and the government's 20% of my concern. so what i do is i take my eye off my patient 20% of the time to make sure i'm complying with what the national institute of comparative effectiveness says, even if it's not in my patient's best interest. when we pass a bill that is going to subterfuge or undermine

the advocacy of physicians for their patients, the wonderful health care that we have in this country is going to decline. now, there's a lot of other things about this bill i don't agree with, but the number-one thing as a practicing physician that i disagree with is the very fact -- mr. president, could i have order and ask for the people to have their conversation off the floor. the presiding officer: the chamber will come to order. please carry your conversations off the floor. mr. coburn: the thing i'm most opposed to as a practicing physician -- i like best practices. i use vanderbilt's in my practice. i like them. they help me. they make me more efficient. they make me a better doctor. but they're not mandated for me when i see something that in my judgment and in the art of medicine i get to go the other way because i know it's what's best for my patient. and what we have in this bill -- in this bill -- is we have what

we passed with the stimulus bill, the comparative effectiveness panel, which is utilized in this bill, and we have the medicare advisory commission saying we're going to cut -- you've got to cut. where do we cut? whose breast cancer screening do we cut next year? when we have the commission say we have to unless we act affirmatively another way, what we are doing is dividing the loyalty of every physician in this country away from their patient. they are no longer 100% advocate for their patient. this is a government-centered bill. it's not a patient-centered bi bill. so going back to the mikulski amendment and what's going to come with murkowski, the murkowski amendment is far better. it does everything mikulski does but doesn't divide the loyalty or advocacy of the physician. and here's what it does. the murkowski amendment says

nobody steps between you and your doctor. nobody steps between you and your doctor. not an insurance company, not medicare, not medicaid. and we use as a reference the professional societies in this country who do know best, whether it -- and mammograms, for example, whether it be the american college of surgeons, the american college of obstetricians and gynecologists, or the american college of oncology. or the american academy of internal medicine. or the american college of physicians, which have come to a consensus in terms of what best practices are, but don't mandate what will or won't be paid for when, in fact, the art of medicine is applied to save somebody's life, like sheila. for, you see, if this bill passed, sheila would have lived two years instead of 12.

10 years was really important to her family. she got to see the children that i delivered for her grow up. one of them she got to see married. but if we decide the government's going to practice medicine, which is what this bill does, the government steps between the patient and their caregiver deciding in washington what we'll do, what you will have is 80% of the time good outcomes and 20% of the time disasters. that's not what we want. i don't deny there's plenty of problems in my profession in terms of not being as good as we should be, of not having our eye on the ball some of the time, of

making mistakes some of the time. i don't deny that. but what i do embrace is most people who go into the field of medicine go in for exactly the right reason, and that's to help people. and it is so ironic to me that we have a bill before us that limits and discourages and takes away the most altruistic of all efforts, which is to do 100% of the best, right thing for your patient. and the reason having hrsa or the secretary set guidelines is bad is because most patients don't fit the textbook. here's what the textbook says, but this patient has this condition, this history, and this finding that are different.

so what we've done in this bill is multiple times take the learned judgment of caregivers and say you will bow to what the federal government says. you will bow to what hrsa says. you will bow to what the secretary of h.h.s. says. you know, 75 times in this bill there are new programs created. 6,950 times in this bill are requirements for the secretary to setup new rules an -- and regulations. if you don't think that will put the government between you and your care, you have no understanding of health care in this country. and you have no understanding of the problems that we face today because of medicare and medicaid rules that interrupt and limit

-- limit the ability for us to care in the best way for our patients. i'm for the prevention aspects of the mikulski amendment. i think it's a great idea. as a matter of fact, it shouldn't be just about women. it should be about screening for prostate cancer for men as well. it should be about treadmills for people with high cholesterol. it should be about true preventive measures. now, why weren't they included? because what we've done under the mikulski bill i is $892 million over 10 years. and we want to do this for one group, but we won't do it for the other. and if you think the government won't get in between, let me give you three examples right now which violates federal law today, but the center for medicaid services and medicare

services violates law, they ration the folk three things. if, in fact, you're elderly, and you have a complication with your colon, and you are a high-risk patient to have a perforation if you have a colonoscopy, that's when we go in to look at the colon, medicare denies you the ability for you to have a c.t. automated camera-centered swallowed pill colonoscopy, which is being used outside of medicare, but you can't have a video colonoscopy by way of a remote control camera. now, why did c.m.s. eliminate that?

they eliminated it, it cost too much. now, so if you're 87 years owed and you've got a mass in your colon and you cannot have a regular colonoscopy, you can't even buy this procedure. it is against the law. because medicare forbids it. number two -- and this has happened to me numerous times -- women with severe osteoporosis, a loss of calcium in their bones, at 50 years of age, diagnosed with a dexascan in a screening, so they don't get a collapsed vertebra or break a hip, you put them on a medicine. the medicine is expensive, there's to this question. but they really do work. some medicines work for some people, other medicines work for others. once you do a dexiscan, under

medicaid rules, medicare rules, you can't do another one for two years. so you can't check to see if the medicine's working after six months to see if you see an improvement in the calcification of this -- of a woman's bones because medicare has said it's too expensive and we're doing too many of them. rather than go after the fraud in dexiscans, what they did was ration the care. so here we have a woman, you diagnosed her properly, you started her on a medicine, but you have to wait two years. and what happens during the period of time if you're given a medicine that's not working effectively because it didn't work in her case? you have to wait two years and her osteoporosis advances and she falls an breaks her hip -- and breaks her hip because medicare said we're doing too many of them? or take what c.m.s. did to all

the oncologists in this country, they said we're paying too much for epigen, it is an acronym for a chemical that is kicked out by your kidneys to cause you to make red blood cells. well, when you get chemotherapy for breast cancer or colon cancer, like i've had, sometimes that chemotherapy not only kills your cancer, but it kills your blood cells. so because we were using too much epogen, medicare puts out a rule limiting epogen and said unless you have a hemoglobin of x amount, you can't take out epogen and the doctor will get fined if he gives it to you if you don't meet the guideline. so what happens?

well, for 80% of the patients it worked fine. but for those patients who had other co-morbid, other conditions like heart failure or emphysema where significant drops in hemoglobin caused organ failure in other areas of the body, there was no exception made by c.m.s. for a physician to make a judgment in saying this rule shouldn't apply here because this patient's going to end up in the hospital. my oncologist told me of a story of one of his patients that could not get epogen, ended up their heart failure got exacerbated because they became anemic from the chemotherapy, ended up in a ventilator in i.c.u. and died. why did they die? because they got heart failure. why did they get heart fail into your because they got too anemic.

why did they get too anemic? because medicare wouldn't allow him to get the medicine. what is wrong with this bill, what is wrong with the mikulski amendment, is we rely on government bureaucracies to make the decisions about care rather than the trained learned experience truly caring caregivers in this country to make those decisions. and instead of going after the fraud in medicare, which is well in excess of $90 billion a year, we've decided we'll ration care. and they're going to -- they're -- the authors of this bill are going to say, no, that's not true. but when i offered amendments in committee to prohibit rationing of medicare services -- to prohibit it, it was voted down every person who is sponsoring an voted for moving -- and voted

for moving on this bill, voted against the rationing. now why would they do that? because ultimately the feeling is is we know better. washington knows better. we know your patients better. we know how to practice medicine better. we're going to take ivory-tower doctors who don't have real practices anymore, we're going to take retired researchers, and we're going to tell you how to practice. and we're going to save money by limiting what you can get. now, the chairman of the finance committee has said we don't -- we don't truly cut medicare advantage. that the services aren't reduced. well, your own bill on page 869, subtitle c, part c -- i won't go through reading it -- reduces medicare advantage payments.

the differential from $135 a month -- i'll read it to you. the chairman's shaking his head. let me read it to you. and, here, let me also reference what c.b.o. has said. i'll be happy to yield to you if you want to talk now or do you want to let me finish? mr. baucus: i'd like to ask you a question. mr. coburn: i'd be happy to yield to the senator. mr. baucus: what page was that? mr. coburn: 869, subtitle c, part c. mr. baucus: i don't have it right now. but there's no required reductions in fringes or extras. mr. coburn: no reduction in what? mr. baucus: fringes, gym memberships. the bill basically provides that there will be no reductions in guaranteed medicare payments. there's a long list of what

guaranteed medicare payments are. even the medicare advantage companies, which are private companies with officers and they've got stockholders and they've got to report to their board of directors, and they've got all of these administrative courses, huge admin costs, the reductions to medicare advantage are still -- the application of the reductions to medicare advantage plans are the discretion of the officers. the officers can decide if they're not going to cut the fringes. that is, the fringes and those extras that are beyond in addition to the guaranteed medicare benefits. so if -- if an officer wants to, it's his discretion -- mr. coburn: i would reclaim my time and ask to submit for the record, c.b.o.11-21-2009, which shows an average from $159, the

fact is if you like what you've got, you can't keep it for 2.6 million americans. you can say that isn't true. that's what c.b.o. says, they have the numbers, they sent the letter to you. i would be happy to yield. mr. baucus: first of all, let me back up. isn't it true that the med -- the medicare advantage plans are overpaid? mr. coburn: absolutely. i'll agree with you. mr. baucus: is it also through, is there a recommendation that the medicare plans to be paid by an amount of 14%? mr. coburn: i don't know the -- i would agree to you that they're overpaid. mr. baucus: they're overpaid? mr. coburn: yes. mr. baucus: if it's over paid, wouldn't it necessarily mean there's a reduction in payments to each beneficiary? mr. coburn: no. mr. baucus: by definition.

mr. coburn: i disagree with that. mr. baucus: if they're overpaid -- mr. coburn: here's what i would say. this morning the claim made by you and senator dodd is that medicare advantage is not medicare. medicare advantage is medicare law. it was signed into law. it was a part of medicare. you would agree with that? mr. baucus: yes. 2003 i made the mistake and agreed to give the medicare advantage plans way more money than they deserved. and as you said, they're overpaid. mr. coburn: i agree with you. you won't hear that from me. now, how did we get there? how did we get there to where they're over paid? we had an organization called the center for medicare and medicaid services. they're the ones that let the contract, aren't they? they, in fact, are. and 25% of the overpayment has to be rebated to c.m.s. today. you would agree with that?

75% for extra benefits, 25% rebated. how did we get to where they're overpaid? because we have a government organization, a government-centered organization who was incompetent in terms of how they accomplished the implementation of that bill. and what was said by senator dodd this morning, and i confronted him already on it, but it bears repeating, is the patient's choice act eliminates the dollars without eliminating the services, because it mandates competitive bidding with no elimination in services for medicare advantage. so if you really want to save money, competitively bid rather than go through eight pages of reductions by year, by year in the payments that go back to medicare advantage, so we have this complicated formula that nobody who would listen to this debate would understand. i know the chairman understands

it because he helped write it. the fact is is 2.6 million americans, according to c.b.o., will see a significant change in their medicare benefits. medicare advantage is medicare part-c. we've had a kind of a differential made that it wasn't really medicare. it is medicare. and 20% of the people in this country that are on medicare are on medicare part-c, medicare advantage, and they like it. and why do they like it? because most of them don't have enough money to buy a supplemental medicare policy to cover the costs that are associated with deductibles and co-pays and outliars. and so -- and outliars. so as we -- i agree with the chairman. i agree that medicare advantage is overpaid.

i disagree with the way you're going about getting there. but i also disagree taking any of the money that is now being spent on medicare part-c and creating another program. i think all that money ought to be put back into the longevity of medicare. and in case you don't understand how impactful that is, we -- we now owe just in the next 75 years -- actually, we don't owe it. none of the senators sitting here will be around. our kids are going to pay back back $44 trillion in money for medicare that we spent, we allowed to grow. fraud $100 billion, close to to $100 billion a year. we did nothing about, this bill does essentially nothing about. $100 billion a year. that's essentially a trillion dollars every ten years, that if we were to eliminate that which this bill does not, we would markedly extend the life and

lower what's going to come to our children. which -- which leads me to the other important aspect of the health care debate. we know that when you take out the funny accounting, the enron accounting on this bill and you match up revenues with expenses, that you're talking about a a $2.5 trillion bill. and the chairman of the finance committee readily admits he has got it paid for. c.b.o. says you have it paid for. but how does he pay for it? he pays for it for 2.6 million people who like what they got today, they're going to lose what they have got today. he pays for it by raising medicare taxes and then the medicare taxes that he raises he doesn't spend on medicare, he goes and spends on a new entitlement program. think about what we're doing. is there a better way to

accomplish what we're doing -- and, mr. chairman, thank you for allowing me the indulgence to continue this long, and i'll wind up with just a couple of statements and share the floor with you. you know, after practicing medicine 25 years, i know we have got a lot of problems in health care, and i appreciate the efforts of the chairman of the finance committee to try to find a solution for them. it's not a bipartisan solution, but it is a solution. it's a solution that grows the government, that puts the government in charge of health care, that creates blind bureaucracies that tell you -- that step between you and your doctor, and that's one way of doing it. but wouldn't a better way be to do the following: let's incentivize people to do the right thing rather than bureaucratize, mandating how they will do it?

wouldn't it be better to incentivize tort reform in the states? wouldn't it be better to incentivize physicians based on outcome? wouldn't it be better to incentivize good behavior by medical supply companies, d.m.a. drug companies, hospitals, physicians through accountable care organizations, through transparency for both quality and price? we don't have any of that in here. what we have is a government-centered bureaucracies that, according to c.b.o. figures, will add 25,000 federal employees to implement this program. 25,000. if you called the federal government, how long does it take you now to get an answer? and we're going to add 25,000 just in health care. that's an extrapolation, mr. chairman, of the amount of

agencies dividing what c.b.o. says per agency and per cost that will -- that we'll come up with. wouldn't it be better to fix the things that are broken rather than to try to fix all of health care? you know, i heard one of my colleagues today say on the floor -- and i think it's really true -- people in america are upset with us, and i think rightly so. i apologize to the american people for my arrogance. i apologize to the american people for the arrogance of this bill. the thinking that we got it right, that we can fix it in washington, that we don't have to listen to the people out there, we don't have to listen to the people that are actually experiencing the consequences of what we're going to do, the arrogance of saying we can

create a $2.5 trillion program and that we know best. well, you know what? we don't know what's best. and as what -- as senator alexander has said so many times, what really needs to happen is we need to start over. we need to protect the best of american medicine. what is the best? if you get sick anywhere in the world, this is the best place in the world to get sick, whether you have insurance or not. if you have heart disease or vascular disease, this is the best place in the world. it costs too much, there's no question, but it's the best place. if you have cancer, you are one-third more likely to live and be cured of that cancer living in this country than anywhere else in the world for any cancer. it costs too much. this bill doesn't address the true causes of the costs.

what are the true causes of the costs? well, one we know medicare and medicaid underpay and we get a cost shift. that's $1,700 per year per family in this country, so you get to pay three taxes in this country on health care. you get to pay your regular income tax which goes to pay for medicaid. and it also is now starting to pay for medicare as well. you get to pay 1.45% plus your employer gets to pay 1.45% of every dollar you earn for medicare. and then your health insurance costs $1,700 more per year because medicare and medicaid don't compensate for the actual cost of the care because of the government-centered role that is played in terms of the mandates, the rules, and regulations. we have a tort system in this country that costs upwards of of $200 billion in waste a year. 8% of the costs.

90% of all cases are settled with no wrong found at all on the caregivers, and of the remaining 10%, only 3% found anything wrong, so 97% of all the cases, only 10% go to trial. 73% of that 10% are found in favor of the providers, yet we spend all of this money practicing defensive medicine. there's not one thing in this bill to fix that problem. that's 8%. so take your health care premium or your percentage of your health care premium and apply 8%. it's going down the drain because i'm ordering tests that you don't need but i need to protect myself in case somebody tries to extort me with a lawsuit that i know is going to get thrown out. i have to have it there to prove it. then we have inefficiencies. ultimately, what we need to do is protect what is good, incentivize the correct behavior in what is wrong and go after

the fraud in health care with a vengeance, put doctors in jail, hospital administrators in jail. don't slap them with a fine and ban them from medicare. put them in jail. the people that are stealing are -- our grandkids' money, up to $100 billion a year need to go to jail. we pay and chase. we pay everybody and then try to figure out whether they deserve to get paid. nobody else does that, but the government does, and that's who we're getting ready to put in charge of another $2.5 trillion of health care. one of the reasons health care is in trouble in this country is 61% of all the health care in this country is run through the government today. and when you look at tricare for our military, you look at v.a. care, you look at schip, you look at medicaid, there's an estimate that $15 billion a year in fraud in new york city alone on medicaid. that's one estimate. per year, in one city on medicaid.

and then medicare. and we're going to say those are running so good, we ought to move another $3.5 trillion or 15% of the health care to where we're at 76% of all the health care is run by the government. i reject that out of hand. until we can demonstrate we're good at what we do, what we ought to be doing is turning it back. the private sector isn't the answer to everything. i agree with that. i can't stand 80% of the insurance bureaucrats i deal with, but at least i got a fighting chance because they'll call me back when i need to do something for a patient. i never get a call back from medicare. they -- they don't call me back. the state doesn't call me back on medicaid when i need to do something, so i just go on and do it and find somebody else to pay for it. that's the kind of system that we have today. think about the mothers in this

country in a medicaid system where 40% of the primary care doctors in this country won't see their children. that's medicaid. that's realistic medicaid today in our country. and so they've got a sick kid, but they can't get in to the doctor, but they've got insurance, they've got medicaid, but they can't get in. and why can't they get in? it's because only one in 50 doctors last year who graduated from medical school goes into primary care, so we've created an abrupt shortage in primary care. and number two is the payment is not enough to pay for the overhead to see the child. and yet so you have a weeping woman worried about their sick kid and care delayed. if you can't get in, it doesn't matter if you have medicaid. if you can't be seen. and so what happens? we go to the emergency room.

what happens in the emergency room? we spend three or four times as much as we should because that's an emergency department. the doctor has no knowledge of the child or the mother, doesn't want to get sued so we have a 40% defensive medicine cost in the emergency room. the answer's not more government health care. the answer is creating the incentives for people to do the right thing. the only way we get things under control in health care in this country and the only way we create access for people in this country is to decrease the costs of health care. this bill doesn't decrease the costs of health care. and if we want to make sure we continue what's best with american medicine while we fix what's wrong, what we will do is one significant part at a time. i can't imagine dealing with

thousands of -- tens of thousands of more bureaucrats in health care, and i can't imagine the impact that's going to have between me and my patients. it's going to severely impact me. do i want people to -- everybody in this country to have available care? yes. 15% of my practice was gratis. people who had no care had no money, and that moves true with a lot of physicians out there in this country. it's true at a lot of labs, true with a lot of hospitals. it's true with a lot of the providers in this country. they're caring people. and we're going to tie them up. we're going to put regulations and ropes around them. we're going to mandate rules and regulations. and we in our arrogant wisdom are going to tell americans how they're going to get their health care. i certainly hope not. and i'm not thinking about me.

i'm thinking about our kids and our grandkids. i'll end with one last point. i say i will. i may not have my notes with me. thompson reuters, a study put out october 9, this year, very well-respected firm, their estimate of the $2.4 trillion that we spend on health care per year in this country is that between $600 billion and $850 billion of it is pure waste. defensive medicine costs and malpractice is between $250 billion to $325 billion by their estimate.

not one thing in this bill to address that. not one thing. fraud, theirs is between $125 billion and $175 billion per year. not significant in this bill: $2 billion to $3 billion. administrative inefficiency, 17%, between $100 billion and $150 billion wasted on paperwork each year. provider errors, that's me, that's either wrong diagnosis, failure to treat appropriately, it's the smallest of all of them. and what are we doing? we're going to tell the providers -- the hospitals, the medical device companies, the drug companies, the doctors, the radiologists, the labs, the physical therapists -- we're going to tell them how to do it. that's not where the problem is.

my hope is that the american people will come to their senses and say, wait a minute, slow down, stop, fix the important thing -- fix the worst thing first, the next thing second, the next thing third, the next thing fourth. the unintended consequences of this bill are going to be unbelievable. nobody's smart enough to figure all this out. nobody. nobody on my staff, nobody on the finance committee, nobody in majority leader reid's office can predict all the unintended consequences that are going to come about because of this bill. mr. chairman, you've been awfully patient, and i see my colleagues here to offer an amendment. with that i yield the floor. a senator: mr. president? the presiding officer: the senator from oregon. mr. merkley: thank you, mr. president. i rise today to share a few

thoughts about our health care proposal and also to address the amendment of my good friend from maryland, senator mikulski. we've heard the word "arrogant" echo in this chamber, that the bill before us is arrogant. i come to it with a somewhat different perspective. for ten years as a representative of a working-class neighborhood back in oregon as a state legislator, i heard a lot of stories from america's working families, from the working families in my house district back home, a lot of stories regarding health care, a lot of concern that they can't afford health care, a lot of concern that their children do not have appropriate coverage, a lot of concern that their health care is tied to their job and if they lose their job, they're

going to lose their health care. a huge amount of stress from america's families who understand that if you have health care, you have to worry about losing it. and if you don't have it, you have to worry about getting sick. well, that's why we're here today in this chamber debating health care, because so many of us have heard from our constituents. so many of us know from our personal experience what a dysfunctional, broken health care system we have in america. now, sometimes listening to this conversation on the floor, you would think this is a rather complicated debate. but the part of this bill is not that complicated. the heart of this bill is that every single american should

have access to affordable, quality health care and that we can take a model that has worked very well for the federal employees of our nation, a model that encourages competition, a model that says let's create a marketplace whereverry individual, every small business -- where every individual, every small business that currently struggles to get health care has to pay a huge premium for health care, enable them to join a health care pool that will negotiate a good deal on their behalf. well, i think every american who's tried to get health care on their own, every small business that's paying 15% to 20% premium because they don't have the clout of a large business understands that if they could join with other businesses, if they could join with other individuals, they would get a lot better deal.

and americans understand that if there is a large pool of citizens who are seeking health insurance, that insurers are going to be attracted to market their goods. we've seen that in the federal employee system, where insurers come and compete. it turns the tables. it takes the power away from the insurance companies, and it gives the power to the american citizen because now the citizen is in charge. now the citizen gets to choose between health care providers instead of having to search for anyone who they can possibly get a policy from. so i don't find that it is arrogant to try to create a system in which individuals and small business get a more affordable health care. i don't find that a bill that says we're going to invest in

prevention, that's not arrogant. that's smart. i don't find a bill that says we're going to create incentives to do disease management so someone suffering from diabetes has their disease managed rather than ending up with an expensive amputation of their foot. that is intelligent. that is not arrogant. i don't find that having a bill that says that every single american is going to find affordable health care, and if they're too poor to afford it, we will provide a subsidy to assist them. get everyone in the door, that is not arrogant. that is saying we are all in this together as citizens, that health care is a fundamental factor in quality of life. it is a fundamental factor in the pursuit of happiness. it's not arrogant to fight for

fundamental access to health care. now, i rise specifically to address the amendment offered by my good friend from maryland, senator mikulski. the legislation we are considering has many parts that make health care more affordable and available, expand access, many parts to hold insurance companies accountable. but a big part of health care reform also deals with helping people avoid illness or injury in the first place. that is what senator mikulski's amendment does and why it's so important that it be included in this package. preventative screening saves lives. that is a fact. early detection saves lives. that is a fact. too many women forego both

because of the cost. i want to share a story from a physician in oregon. the physician is dr. linda harris. and i'm going to quote her story in full. it's not that long. she says: "i work one day a week at our county's public health department. there i met sue, a 31-year-old woman who came in with pelvic pain and bleeding. she proved to have extremely aggressive cervical cancer that was stage 4 when i diagnosed it. when sue was 18, she had a tubal ligation after she gave birth to her only child. as a single mom, she did not have the financial resources to have more children. she concentrated on raising her daughter. sue always worked, sometimes two jobs at once, but never the kind

of job that offered health insurance. but because she had a tubal ligation, she did not qualify for our state's family planning expansion project that provides free annual exams, pap smears and contraceptive services to many of our clients. " the doctor continues: "cervical cancer is an entirely preventible disease. pap smears almost always find it in its preinvasive form, but sue never came in for a pap smear or an annual exam. her lack of affordable access to basic health care proved fatal. when sue died of cervical cancer, her daughter was 13." that is the completion of the story that the doctor shared. and sue shouldn't be viewed as a

statistic in a broken health care system, but instead we should take her story to heart about the importance of preventative services. sue is one of 44,000 americans who die each year because they lack insurance. according to a recent harvard medical school study. let me repeat that statistic because i think it's hard to get your hands around. 44,000 americans die each year because they lack insurance. i don't think that it is arrogant to say we should build a health care system that gives every single american access to affordable quality care so that 44,000 of our mothers and

fathers, our sons and brothers, our daughters, our wives, our sisters, so that 44,000 of them do not die each year because they lack insurance. senator mikulski's amendment will help keep this tragedy from happening to our families. to put it plainly, it will save lives. it does this by allowing the health resources service administration develop evidence-based guidelines to help bridge critical gaps in coverage and access to affordable preventative health services. the same approach the bill takes to address gaps in preventative services for children. this will guarantee women access to the kinds of screenings and tests that can prevent illnesses or stop them early. as the american cancer society cancer action network notes -- quote -- "transforming our

broken sick-care system depends on an increased emphasis on prevention and early detection, enabling us to find diseases like cancer when they are easier to survive and less expensive to treat." that last point is also important. treating illnesses also saves money. with so much emphasis on the cost of health care, we should all agree that it's common sense to include reforms that lower health care costs for all americans. i was noticing that her amendment has a long list of organizations stating how important this is. the national organization for women, the national partnership for women and families, the religious coalition for reproductive choice, the american cancer society, cancer action network, the national family planning and reproductive health association. i applaud senator mikulski for

offering this amendment. i urge my colleagues to remember the 45,000 americans who die every year because they do not have access to insurance. they do not have access to preventative services, and vote to include this important reform. thank you, mr. president. ms. murkowski: mr. president? the presiding officer: the senator from alaska is recognized. ms. murkowski: thank you, mr. president. i ask unanimous consent that i be permitted to engage in a colloquy with my republican colleagues o on an amendment tht i will be discussing. the presiding officer: without objection. it is so ordered. ms. murkowski: thank you, mr. president. a great deal of discussion certainly this week and last with the announcement from the united states preventive services task force, the uspstf,

the recommendations as they relate to mammograms, and the recommendation that women under the age of 50 do not need to be screened until they reach age 50 and then on attaining the age of 50, every other year after that. when these recommendations came out on the 16th of november, i think it is fair to say that they generated a level of controversy, a level of discussion, and really a level of confusion around the country by women from all walks of life. i think for many, many years now women have operated under what we knew to be the standards, the protocols. if you had a history of breast cancer in your family, obviously, you took certain steps earlier, but the general recommendation that was out there -- certainly the

guidelines that we had been following, the assurances that we were seeking as women would be that we would be encouraged to engage in these screenings on an annual basis, and they gave us all a level of confidence. when the -- when these new recommendations, these new guidelines, came out then just a couple weeks ago, i really do think that the level of confusion, the level of anxiety that was raised because of this announcement brought a focus to some of what we are talking about here today when we discuss health care, health care reforms, and how the forms -- should the government be involveinvolved in our health c. i know that i have received e-mails from friends, e-mails from relatives, girlfriends that i haven't heard from in a while,

talking with women just generally about, well what do you tbhi this. and you would hear -- well, what do you think about this. and you would hear story after story about the woman that discovered at age 39 a lump, something that was off, something that was not right, and then the stories subsequent to that, the steps that she took as an individual with her doctor. but, again, the announcement that, well, we now have these guidelines that this preventive screening task force has put in place, and everything that we thought we knew and understood about what we should be doing with our health has been unsettled. so it brings us to the discussion today. we have an amendment brought to us but the senator from

maryland. and i would like to offer up a little bit later an amendment, but i'd like to speak to that amendment now, if i may. i'm proposing this as a side-by-side to senator mikulski's amendment. and this is designed to allow for an openness, a transparency on preventive services, not just mammograms. i don't want to limit it to just mammograms because we know that preventive services and so many other aspects of our health are also equally key and also equally important. but what i'm looking to do with my amendment is to rely on the expertise, not of a government-appointed task force, but to rely on the expertise of medical organizations and the experts, whether they are within

the college of ob-gyn's or surgeons or oncologists, rely on them and their expertise to determine what services, what preventive services should be covered. what we're seeking to do is allow for a level of information so that the individual can select the insurance coverage based on the recommendations by these major professional medical organizations on preventive health services, whether it's mammography or cervical cancer screening. i think we learned from the announcement from the uspftf, the preventive services task force, that when we have government engaging in the

decisions as to our health care and what level -- what role they actually play, there's a great deal of concern and consternation. i heard from many of my colleagues on both sides of the aisle here, well, that task force was wrong. we think that they have made a mistake in their recommendations. well, what we're intending to do with this amendment is keep the government out of the health care decision making and allow the spotlight to be shone on the level of prevention coverage that patients will get under their health care plan. so, rather than relying on unelected individuals -- basically these are individuals that are appointed by an administration to serve as part of this panel of 16 on the u.s. preventive task services task

force. my amendment says that they must consult the recommendations and guidelines of the professional medical organizations in determining what prevention benefits should be covered by all health insurance plans here in this country. and i -- i know that -- at least knowthose of us who are on the federal employees health benefits, we have an opportunity to subscribe to the blue cross-blue shield plan. you look to their -- this is under their standard and basic option plan and you turn to the preventive care for adults that is covered. and they provide under this particular plan for the cancer diagnostic test and screening procedures for colorectal cancer tests, for prostate cancer, cervical cancer, breast cancer, there is a thrais we can look

to. but what we don't -- there's a list that we can look to. but what we don't really see laid out in this booklet or any other pa pamphlets that outline given plans out there, for example on the breast cancer test, is there an age restriction? i'm told under blue cross there is not. but it doesn't indicate that there. what do the experts recommend? it's not clear from what we receive. and so what my amendment would do, in part, is to allow for this information to be directly made available to patients, to individuals that are looking at the plans to make a determination as to what they will select. if you go to the web sites of these medical professional -- professional medical organizations -- for instance, the american

congress of obstetricians and gynecologists. they recommend that cervical cancer screening should begin at age 21 years, regardless of sexual history. conserve s&l sightology screening recommended every two years for women between the age of 21 years and 29 years. american so site of clinical oncology, as to the recommendations for mammography urges all women beginning at age 40 to speak about thei with ther doctors -- to speak with their doctors about mammography. the american college of surgeons in their recommendations recommend that women get a mammogram every year starting at age 40. as an individual that is looking to make a determination as to what are the experts saying out there, what is being recommended, i would like to know that this information is made available to me, to help me make these decisions.

so what our amendment would require is the plans would be required to provide this information directly to the individuals through the publications that they produce on an annual basis. so what we are taking about now is it is the doctors, it is the specialists that will be recommending what preventive services to cover, not those of us here in washington, d.c.,, in congress, not the secretary of health and social services who may or may not be a doctor or medical professional, not a task force that has been appointed by an administration. we're trying to take the politics out of this and really put it on the backs, if you will, of the medical professionals who know and understand this. this is where i think we want to be putting the emphasis.

this is where we want to be relying is on the professionals, not the political folks. additionally, my amendment ensures that the secretary of health and human services shall not use any recommendations made by the united states preventive services task force to deny coverage of any items or services. this is the crux of so much that we're talking about right now with these latest recommendations that came out by uspstf. the big concern by both republicans and democrats and everyone is that the insurance companies are going to be using these recommendations now to deny coverage to women under 50 or to a woman who is over 50 if she wants to have a mammogram every year, that only -- she would only be allowed coverage for those mammograms every other year, rather than on an annual

basis. we want to take that -- that away from the auspices, if you will, of the government, to suggest that we will deny coverage based on the recommendations of these task -- this government task force is not something that i think most of us in this country are comfortable with. so we specify very clearly that the secretary cannot use any recommendations from the uspstf to deny any services. we also include in the amendment broad protections to prevent, again, the bureaucrats -- the government folks at the department of health and human services from denying care to patients based on the use of comparative effectiveness research. and then finally, we include a provision that ensures that the

secretary of health and human services may not define or classify abortion or abortion services as preventive care or as preventive services. mr. president, this amendment is relatively straightforward. it relies essentially on the recommendation of practicing doctors as opposed to the bureaucrats, to the politicians, to those in office. my amendment addresses the concern that the government will make coverage determinations for your health care decisions. what we're doing here, quite simply is making it very transparent, making clear that the preventive services that are recommended by the professional medical organizations are visible, are transparent. we require the insurance companies to disclose that information that is recommended,

and, again, recommended by the professionals. i think that this is a good compromise amendment. it basically keeps the government out, and it keeps the doctors in, and it requires the insurance companies to disclose the information to the potential enrollees and allows for, again, a transparency that i think to this point in time has been lacking. mr. president, it's been suggested by at least one other member on the floor earlier that my amendment would cost somewhere in the range of, i believe it was said, $30 billion. i would like to just note for the record, we have not yet received a score on this. we fully believe that it will be much, much less than has been suggested. i think when the statement was made, it was not with a full view of the amendment that we

have before us and is not consistent with that. so i did want to just acknowledge that, as we begin the discussion on my amendment. mr. enzi: first, i wanted to thank the senator from alaska for the tremendous work that she has done on this and the dozens of people that she's talked to over the last couple of days to try to come up with an amendment that would actually solve the problem that everybody has been talking b i appreciate the senator from maryland recognizing this major flaw in the bill. and it is in the bill. the u.s. preventive services task force is in the bill and that's exactly the group that specified this new policy on mammograms that's upset people all across the country. it upset people so much that we have an amendment on the floor by the senator from maryland reacting to that and reacting to the fact that it is in the bill at the current time.

so i appreciate the senator from alaska coming up with a plan that actually is more comprehensive i think than th the -- than the amendment from the senator from maryland because you've had a little bit longer to work on it. and i appreciate the words that you've got in there that you cannot deny -- you're on the health, h education, labor, and pensions committee with me, and i know we worked this issue in committee, and i hope that this kind of a realization would be made at that time. we had some amendments that said they couldn't deny based on this or the comparative effectiveness or couldn't prohibit based on it. and we know from our amendments that all of those failed, meaning that there was probably some intention to deny or to prohibit based on these groups. and so i appreciate you bringing up the fact that -- that it is the caregivers that will have

some say in this so that washington can't come between you and your doctor. and i -- i wish you'd go into a little bit some of your background from alaska because you and alaska have been very involved in breast cancer for a long time, and people ought to be aware of the kind of services that are available throughout and what cost those are. ms. murkowski: well, i appreciate the question from my colleague from wyoming. you know coming from a rural state that our health care costs are -- are typically higher, and it's not just an issue of cost but it's an issue of access. and particularly in my state, where most of our communities are not connected by road, it is very difficult to gain access to a provider. it's even more difficult to gain access to, for instance, the mammography units. i have been involved in this

issue just in terms of -- of women's health and cancer screening for -- for many decades now, primarily because my mother got started in it back when i was still in high school and saw a need to provide for screening, breast cancer screening for women in rural areas where they couldn't afford to fly in to town, as we would call it, for the screenings. and so she engaged in an effort and continues to this day to raise money for not only mobile mammography units but to figure out how we move those units from village to village. and essentially what they've been able to do over the years is you put that mobile mammography unit on a -- on the back of a -- of a barge and you take it up and down the river and you stop in every village and offer free screenings for --

for women. fly it into a village where you're not on a river. and we have been making this effort again for decades, and i think working, chipping away slowly at -- at the issue of breast cancer. i think we recognize that in our state, particularly with our alaska native populations, we see higher levels of breast cancer than -- than we would like. we're trying to reduce that. but when these -- when these recommendations came out several weeks ago from usgspf, i will tell you, the buzz around my state amongst women about, well, now what do i do, where do i go, do i need to go in for my screening, whawd what shoul wha. there was an article, it was actually in the news just a, i

guess, a couple of weeks ago, and it cites a comment from a doctor and her comment was that the new recommendations were confusing patients who usually come in for their annual screenings. and she says, "my schedulers have called to schedule patients to come in for their follow-up mammogram and they've been told, well, i don't have to do that now. this government group says i don't have to do that." now, mr. president, and my colleague from wyoming, you know, maybe some don't, but what about those who are at risk, and these are the ones that i think we're continuing to hear from and say, please, add some clarity to this. mr. enzi: well, mr. president, i know that there isn't any word that probably turns a family upside-down quite as much as the word "cancer," and it doesn't matter which form of cancer it is, it's -- that -- it's just

drastic because you don't know all of the implications of it. maybe someday we will. maybe someday we'll know how -- how people get it and we'll be able to cure it with a vaccine. but so far what we have are some mechanisms for putting it into rescission. and one of the reasons i know how upsetting that is and how it turns the world upside-down is 3 1/2 years ago -- 3 3/4 years ago now my wife was diagnosed with colon cancer. and she had had screenings, but she listened to her body. she said, something's the matter here and she kept going to doctors. so even if they don't recommend the screenings, if your body is saying something is the matter, pursue it until you're either convinced that nothing's the matter or a doctor finds what's the matter. that's the advice that she gives to everybody. and these -- these are things that need to be between the patient and the doctor. now that she's in remission, one of the things that the doctor recommended was that she take

celebrex. that's something that's normally for arthritic pain. but what they've found is that in some patients, that will keep polyps growing that will turn into cancer in the colon. -- polyps from growing that will tush intturn into cancer in the. she's taking that. but it's a constant fight making sure that's an approved medication and that it can be ton and that it will be paid for. if that were just a task force recommendation, first of all, since she the screening, they would say she doesn't have a problem. and later she would die from it. but she was able to listen to her body, get the treatment that she needed and now is continuing to get the treatment without a task force saying, no, 99% of the people don't need that. her doctor and she are able to determine what she needs. on other screenings, once you have cancer, there are other times that you need to have

m.r.i.'s, other kinds of tests run. that again has to be up to the doctor and the patient to determine how often those are. and, again, i know from talking to a number of people that i know -- not just ladies either -- that have had cancer, that once you've had cancer and you're in remission, you would actually prefer to have your screening just a little bit earlier for the mental reassurance that you get with it. and again from talking to people -- and we talk to more now because we're trying to give some reassurance to them when this terrible word comes up, that when they go to the doctor, one of the first things that happens is they -- they weigh you and they take your blood pressure. and when you're waiting for a decision on how the blood tests you got or the m.r.i. or whatever it was is coming out, that blood pressure just goes through the roof. and quite frequently, you can't leave the doctor's office until

you've gotten the -- you went there for the information, so of course, you stay for the informing. but they won't let you leave until they do the blood pressure test again to make sure that it goes down below the critical stage. that's how -- that's how much impact this -- this has on people. so i'm -- i'm really glad that did you something -- that you did something that keeps -- that goes a little bit further, covers a few more things, and makes sure that people are going to have access to their doctor, to the tests that they need, and not be relying on some government bureaucracy to say, well, in 99% of the cases or 85% of the cases -- who knows how far down they take it, depending on what the costs are. and we just don't want that to happen. and i think that your amendment allows patients to get these preventive benefits and stops government bureaucrats and outside experts from ever blocking patients' access to those types of service. i appreciate the senator from

maryland, who put up an amendment. i don't think it meets that standard. they still rely on government experts called the u.s. preventive services task force to decide what preventive benefits should be covered under the private health insurance. and it's the same preventive services task force that made this decision that under the age of 50 should not receive annual mammograms. in fact, i think i even remember in there that they weren't necessarily recommending sel self-examination. most of the people that i know that are really young discovered it with self-examination, and i certainly wouldn't want them to quit doing that because there's a recommendation from somebody that doesn't understand them or their body for doing that. patients do want to receive preventive screenings. sometimes they're reluctant to do it because nobody wants the possibility of hearing that word given to them. so americans should be able to get screened for high blood pressure, diabetes. when the doctor recommends these

get these tests. i think you and i agree that they should be able to get colonoscopies, prostate dpams, , mm grams so they can -- mammograms so they can prevent cancers when they are present from progressing so they are no longer curable. many of these diseases are preventable or curable or put into remission if they're discovered early enough. i think we agree that senator mikulski's goal that all americans should be able to get preventive benefits, but we disagree that her amendment achieves that stated goal. her amendment does not ensure access to mammograms for women which returned the age of 50. and part of that i'm taking from an associated press article. as most americans know, last month the preventive services task force revised the recommendation for screening for breast cancer, advising women between the ages of 40 and 49 against receiving routine mammograms and women ages 50 and over to receive a mammogram just once every two years. the u.s. preventive services task force lowered its grade for these screenings to a "c," and

that sparked the political firestorm as many women became confused about what services they could get and when they could get them. and the health care bills before congress further confused the issue because they rely heavily on the recommendations of that fosk force. that's what's in -- of that task force. that's what's in the bill. the underlying reid bill says and the mikulski amendment restates that all health plans must cover preventive services that receive an "a" or a "b" grade from the task force. let's see. we just said that was a "c" grade. because breast cancer screenings for women under the age of 50 are no longer classified by the task force as a or b plans, they would not cover those services. so senator mikulski, the senator from maryland's drafted amendment to try to fix this problem but it i think confuses the matter some more and i appreciate the effort that you've gone to to try and clarify that and expand it to some other areas. so -- and not add another layer of bureaucracy by saying that

all services and screenings must be covered by health plans. however, the previous amendment doesn't have any -- any guidelines that are specifically for women or prevention, so -- ms. murkowski: if i may just comment on your last statement there, because i think this is -- this is very important for people to understand. there's been much said about the mikulski amendment and what it does or doesn't do, but it is very important for women to understand that the mikulski amendment will not address, will not provide for those mammograms for women that are younger than age 50. her amendment specifically provides that it is evidence-based items or services that have, in effect, a rating of a or b in the current recommendations of the united states preventive services task

force. gow to the task force -- so you go to the task force report, and as you have noted, women who fall between the ages of 40 and 49 receive a grade of a "c," and the recommendation is specifically do not screen routinely. individualized decision to beginning by enannual screening according to the patient's context and values. but they have received a c by the usgspf. so according to the mikulski amendment, those women who are younger than 50 years of age will not be eligible or will not be covered under the mandatory screening requirement that she has set forth in her amendment. i think that's where she was trying to go, was to ensure that these recommendations would not be used to deny coverage and she

adds a paragraph stating that "nothing shall preclude health plans from covering additional services recommended by the task force that are either not an a or a b recommendation." but the amendment does not require plans to cover services that are not an a or a b. so, in other words, if you are 45 years of age, you are in this c category and the amendment does not require, then, that your preventive screening services be covered. so for those women who are in -- in this age group -- yo you kno, congressman -- excuse me -- congresswoman debbie washman schultz went through a bout of cancer and it was diagnosed at age 41, i believe. for those women who fall in this

category, this amendment that this senator from maryland has introduced, does not address the concerns that have been raised by these recommendations coming out of this preventive task force. and, again, i think we need to -- to understand that what this amendment specifically allows for is -- is first dollar coverage for immunizations or for children -- children's health services as -- as outlined with the hrsa, health resources and services administration guidelines. but, in fact, the -- the requirement, again, to provide for screening coverage for women who -- who are not in this a or b category, in other words, anybody younger than 50, you need to understand that you are not covered through this.

our amendment through -- through allowing for a -- a level of transparency, ensuring that when you go to -- to obtain your insurance, you can see very clearly what the medical -- professional medical organizations recommend are the guidelines and then what your insurer is proposing to offer you for your coverage. and if it's not coverage that you like, then shop around. this is what -- this insurance -- what this insurance exchange is supposed to be all about. mr. enzi: mr. president, i want to congratulate the senator from alaska also. isn't it true that your amendment ensures that the secretary of health and human services won't be able to deny any of these services based on any recommendation? that's one of the things that we've been concerned about. again, that's an unelected bureaucrat who could come between you and your doctor and your health care and i think -- i know that you covered that in

your amendment too. and i do appreciate it. ms. murkowski: well, it states very clearly on the second page that the secretary shall not use any recommendation made by the united states preventive services task force to deny coverage of an item or service by a group health plan or health insurance issuer. so, yes, we make very clear that these recommendations from the -- the ustspf cannot be used to deny coverage. now, i think the -- the opportunity to have medical professionals, as is -- is this usgspf is comprised of, we should have -- we should have an entity that is kind of looking out an seeing what best practices are. but then that entity should not be the one that -- that causes a determination as to whether or not coverage is going to be offered. you can use that as a resource,

most certainly, just as we use as a resource the recommendation from -- from -- say, for instance, the american congress of obstetricians and gynecologists, the american college surgeons, the american society of clinical oncology. it is not going to be the determining factor. this is where we need to make this separation and where my amendment separates from senator mikulski's. mr. enzi: and i also appreciate that you make sure that they cannot deny care based on the comparative research which was on the stimulus bill that was run through at that time. and your amendment provides a commonsense provision that would prohibit the secretary from ever determining that abortion is a a preventive service. i hope all of my colleagues whether pro-life or pro-choice

are aware of this change. what we're talking about is the preventive issues, and i appreciate you covering that. ms. murkowski: i'm glad that you mentioned the issue of the abortion services. i think there is a vaguery, a vagueness in the -- in the amendment that senator mikulski has offered. some have suggested that it would allow those in human resources and services administration, hrsa, to define abortion as a prehaven'tive test which could provide health insurance plans that then be mandated to cover it. and that has generated some -- some concern obviously. some opposed the amendment saying that if congress were to grant sweeping authority to define services that private plans might cover merely to constitute preventive care, that authority could be imemployed in

the future to require all health plans to cover abortions. what we're doing in my amendment is just making very clear there are no vagueries -- there is no second guessing. it just makes very clear that the secretary cannot make that determination that -- that preventive services are -- are to include abortion services. mr. enzi: mr. president, as i said before, my wife says that she probably never mentioned the word colon twice in her whole life. since then she's become an encyclopedia for people who had a similar problem. she had a colonoscopy just a short time before she was having problems and they had said there is no problem. she kept getting it checked until she found there was a problem. so people need to listen to their bodies and they need to listen to their doctors and they shouldn't have a bureaucrat coming in between. so thank you for all of your effort on this. ms. murkowski: well, i thank you

for the dialogue here today. this is an important part of our discussion as we debate health care reform on -- on the floor. we've had good conversations already yesterday and today about the cuts to medicare, the impact that -- that we will feel as a nation if -- if these substantive cuts advance. but i think this discussion, and we're narrowing it to so much on what the recommendations have been from this task force. but i think it is a -- a good preview of -- of -- of what -- what the american people can expect if we move in the direction of -- of government-run health care. of -- of bureaucrats, whether it's the secretary of health and social services or whether it's task forces -- task forces that have been appointed by those in the administration who are then

able to make that determination as to what is best for you and your health care and your family's health care. and i -- i -- i think the discussion that we have had today about ensuring that it's not -- it's not best left to these -- these entities -- these appointed entities to make these determinations, but let's leave it to -- or let's allow the information to come to us from the medical professionals. senator coburn has spoken so -- so eloquently on the floor about relying on those who really know and understand, who live this, who practice this rather than us as -- as politicians who want to be doctors. i don't want to be a doctor. i want to be able to rely on the good judgment of a provider that i trust. and i want him to be able -- him or -- he or she to be able to

make those decisions based on his understanding of me and my health care needs and what is best for me and what the best practices are that are out there rather than him having a task force telling him that's the protocol for lisa. she's 52. she's able to get a mammogram every other year now. i want to know that it's me and my doctor that are making these decisions. i -- i would hope that members would take a look at -- at the amendment that -- that i will offer up and -- and consider how it allows for truly that kind of openness, that kind of transparency and gives -- gives individuals the freedom of choice in their health care that i think we all want. with that, i thank my colleague from wyoming, and i yield the floor.

a senator: mr. president? the presiding officer: the senator from montana's recognized. [inaudible] the presiding officer: without objection, it is so ordered. mr. enzi: mra senator: mr. pres? the presiding officer: the senator from rhode island is recognized. mr. whitehouse: i thank the presiding officer, and i'm delighted to be on the floor with the distinguished member of the finance committee and the distinguished senator from michigan, who has worked so hard on these issues. i'm sure that i won't be the only person to say this, but i would like to respond to the colloquy between the senator from wyoming and the senator from alaska. because as i understand it, the mikulski amendment provides for preventive services that are the a and b category as a floor, not a ceiling at a minimum. and it instructs the health

resources services administration to cover -- to provide recommendations and guidelines for comprehensive women's preventive care and screenings. and once that is done, then all plans would be required to meet them. totally apart from the a or the b. in terms of the health resources services administration being a -- a bureaucrat who wants to get between you and your doctor, these are actually scientists, not bureaucrats. it's an independent panel and it comes, i think, with some irony to hear the concern expressed on the other side of the aisle repeatedly. about -- repeatedly about bureaucrats coming between americans and their doctors and telling them what care they can and cannot have when my

experience in rhode island leading up to this debate, your experience, mr. president, in illinois leading up to this debate, senator stabenow's experience in michigan, leading up to this debate, all of our experience in our home states leading up to this debate has been the problem has been that the private for-profit insurance industry is out there denying care every chance it gets. i think the -- the distinguished senator from illinois was presiding when i told the story of a family member of mine who died recently who was diagnosed with a very, very serious condition. he went to the national institute of health to get the best possible treatment. he got the possible specialist on his particular diagnosis in the country and when he took that back to new york, his insurance company said, i'm sorry, that's not the indicated care. that's just one experience that i've had. hundreds of rhode islanders have been in touch with me about their nightmare stories over and

over again. whether it's because you have a preexisting condition and they won't insurance you? or -- insure you. or once you get diagnosed they won't awtsd rise your doctor to proceed with the care that you need. or if you get the care, they'll do everything they can to avoid paying the doctor and create a bureaucratic headache for the doctor. the private insurance industry is standing between you and the care you need and i have not once -- not once since i have been here heard anybody on the other side of the aisle express any concern about the bureaucrats between you and your doctor as long as it's an insurance company bureaucrat, it seems to me that they actually approve of bureaucrats getting between you and your doctor as long as it's a bureaucrat that's an insurance company bureaucrat that has a profit motive to deny you health care. then it's okay. then they don't complain. but when it was independent scientists working hard to

generate the best science that can be done so that people get the best information to make decisions, then suddenly -- then you hear about bureaucrats. i think that people listening to this should have that history in mind as they evaluate this claim that we are trying to put bureaucrats between you americans and their doctors by stripping the abuses away from the insurance company. this bill does more to relieve that problem than any piece of legislation i can think of. the distinguished senator from michigan. ms. stabenow: thank you, mr. president. i want to thank my colleague from rhode island because i couldn't agree more with what you just said in terms of who's standing between -- in this case on this issue a woman and her doctor or any patient and their doctor. right now i -- i assume you would agree with me that the first person, unfortunately, that the doctor may have to call is the insurance company to see whether or not he can treat

somebody. to see what it's going to cost. is it covered? right now we know that half the women in this country, in fact, postpone -- delay getting the preventive health that they need because they can't afford it. and so the mikulski amendment, from the distinguished senator from maryland, is all about making sure women can get the prehaven'tive care that we -- preventive care that we need. whether it's the mammogram or cervical cancer screening, whether it is focusing on pregnancy. wouldn't you agree right now in the marketplace, i understand about 60% of the insurance companies in the individual market don't cover maternity care. they don't cover prenatal care. they don't cover labor and delivery and health care through the first year of a child's life. that's standing between a woman, her child, and her doctor. that's the ultimate standing between a woman and her doctor,

is to say we're not going to cover that. i think one of the most important things we're doing in this legislation is to have as basic coverage something as basic as maternity care. when we are 29th in the world and the number of babies that make it through the first year of life, that live through the first year of life, that is something that we should all be extremely outraged about, concerned about. this legislation is about expanding health care coverage, preventative care, making sure that babies and moms can get prenatal care, that babies have every chance in the world to make it through the first year of life because we have adequate care there. and yet, the ultimate standing between a woman and her doctor is the insurance company saying we don't think maternity coverage is basic care.

mr. whitehouse: senator stabenow, it's the business model of the private health insurance industry right now. they want to cherry pick out anybody who might be sick, and that's why they have the pre-existing condition exclusion, and then they have this absolute army of insurance company officials whose job it is to deny care. i wept to the cranston, rhode island, community health center a few months ago. it's a small community health center providing health care in the cranston, rhode island, area, and it doesn't have a great big budget, and i asked them how difficult is it to deal with the insurance companies in order to get approval and in order to get claims paid, and they said well, senator, 50% of our personnel are engaged not in

providing health care but in fighting with the insurance industry to get permission for care and to get claims paid. 50%. ms. stabenow: would the senator please repeat that again? that's astounding to me. you just said 50%? mr. whitehouse: 50%, 5-0. half of the staff of the community health center was dedicated to fighting with the insurance industry and the other half was actually providing the health care. in addition, they had to have a contract for experts, consultants to help fight against the insurance industry. that was another $200,000. $200,000 for a little community health center plus half their staff. and what you've seen in the past -- i think it's eight years -- is that the administrative expense of the insurance industry has doubled, and that's what they're doing. it's like an arms race. they put on more people to try to prevent you from getting care because it saves them money when

they do. they have a profit motive to deny you. in the case of my -- the member of my family who they tried this on, he had the fortitude to fight back and eventually they caved. but for every person like him who fights back and actually gets the coverage that they paid for, that they're entitled to, there are going to be some who are too ill, who are too frightened, who are too old, who are too weak, who are too confused, who simply don't have the resources when they're burdened with a terrible diagnosis like that to fight on two fronts, and so they give up and the insurance company makes money. it is systematized. not once have i heard anybody on the other side of the aisle in this senate complain about it. it is a scandal across this country. it is the way they do business. i don't think there's a person on this floor who hasn't heard a story of a friend or a loved one or somebody they know and care about who has been through that process. it's not hypothetical.

it is happening now. it is happening to all of us. but it's only when we come in and try to fight that that suddenly this concern is raised about, oh, my gosh, you're going to get bureaucrats. they just happen to have no profit motive, work for the government, be trying to do the right thing and be experts. and suddenly it's no good. ms. stabenow: as the senator from rhode island has said so eloquently, we have all had situations like this happen in our own families, and everyone listening, everyone involved in the senate family has certainly had that as well happen to us. i found it very interesting, every tuesday morning we invite people from michigan who are in town to -- to come by and we do something called good morning, michigan, and not long ago a woman came in and she said i'm so excited, i'm finally 65 and i can choose my own doctor because i'm going to be on medicare. medicare, of course, as we know is a single-payer government-run

health care system that i could not get my mother's medicare card away from her if i had to wrestle her to the ground because, in fact, it has worked because it's focused on providing health care. that's the mission. one of the things i think is indicative of the whole for-profit health care system -- and bite way, we're the only ones in the world that have a for-profit health care system -- when they talk as an insurance industry, they talk about medical loss ratio. the medical loss ratio, which is how much they have to pay out on your health care. so the language of the insurance industry -- now, it's different if you -- if there's a car accident or if your home is on fire, and we understand you don't want to pay out for a car accident. you don't want to pay out for a home fire, but in this case we have an institution set up through which most of us go. we have over 82% of us in the

private for-profit insurance market through our employers, we're in a system where the provider, the insurance company calls it a medical loss if they have to pay out on your insurance. so i think that alone is something that to me sends a very big red flag if they're trying to keep their medical loss ratio down. now, we have in this legislation been doing things to keep that up. we want them to be paying out the most of the dollars that you pay in on a premium out in health care so the people are getting the health care that they are paying for. that's what this legislation is all about. but as my friend from rhode island has indicated, point by point by point, when we look at every amendment, every amendment in the finance committee -- i would say virtually every amendment from our colleagues on the republican side, and when

welike at the amendment so far on the floor of the united states senate, the first two being offered are about protecting the for-profit insurance companies. making sure that excessive payments that are currently going out for for-profit companies under medicare continue. making sure that we are protecting the industry's ability. not your doctor's ability to decide what care you need, when you need it and so on, but the insurance company's ability to decide what they will pay for, what is covered, when you will get it. and by the way, if you get too sick, they'll find a technicality and they'll drop you. and all of those things we are addressing to protect patients, to protect taxpayers, consumers in this legislation. wouldn't you agree that's what this is about? mr. whies: i -- mr. whitehouse: i do agree. ms. stabenow: it's not about

saving for-profit insurance companies. mr. whitehouse: but there is as the senator has noticed an astonishing similarity, an astonishing similarity between the interests of the private health insurance industry and the arguments made by our friends on the other side on the floor. it's amazing. they are identical, virtually, to one another. i have yet to hear an argument about health care coming from the other side of the aisle that does not reflect the interests and the welfare of the private insurance industry about which for years i never heard them complain while they were out denying care and inserting bureaucrats. we have another good example beyond medicare. i am struck that today is the first day since the president's speech in which he has announced that 30,000 men and women will be going over to afghanistan in addition to the men and women there. all of us in the senate, all of us in america are proud of

their -- of our soldiers. we wish them well. those of us who visit afghanistan know how challenging an environment it is, how difficult it is to be away from one's family. there can be no doubt, i think, in our minds that we want the best for our men and women in the service. we want the best. everybody agrees that we want the best for them. our friends on the other side want the best for them. and when we give them health care, what do we give them that we think is the best? we give them government health care, through tricare and through the veterans administration. so -- and i haven't heard a lot of complaining about that. i haven't heard a lot of complaining about stripping our veterans out of the veterans administration and letting them go to the tender mercies of the private health insurance industry because when there's not an issue that involves the essential interests of the private health insurance

industry, then they'll do the right thing and they'll recognize that that is the best for our service men and women, that is the best for our veterans, and of course they support it. we all do. it makes perfect sense, but it allies the arguments we're hearing today. ms. stabenow: i would totally agree with the senator from rhode island, and thank you for your comments. and what i find even more perplexing is that what we have on the floor is not a single-payer system, even though some of us would support that. it is not. it is, in fact, building on the private system but creating more accountability. we're not saying there won't be private insurance industry. what we're doing is saying that small businesses and individuals who can't find affordable insurance today should be able to pool together in a larger risk pool. this has been, in fact, a republican idea and a democratic idea for years, going back years. what we're saying is you know what? if you want to be able to have access to cover these folks,

we're saying to the insurance companies you have to stop these insurance abuses. so we're not saying you can't offer insurance. in fact, this is a motto like the federal employee health care model where people who don't have insurance today can get a better deal and a big group pool like a big business, small businesses, individuals will go in and purchase from private insurance companies. many of us believe they ought to have a public option in there as well, but we are talking about private insurance companies participating. all we're saying is wait a minute, if you are going to have access to the individuals that now will be having the opportunity to buy insurance, we want those rates to be down, we want them to be affordable. we want to make sure there is no pre-existing conditions. we want to make sure if somebody actually buys insurance and pays for it and pays a monthly premium every month and every month and every month and finally somebody gets sick, that

they don't get dropped on some technicality. we want to make sure that women aren't charged twice as much as men which in many cases is what's happening today, and sometimes for less coverage. we want to make sure that maternity care is considered basic, that women's health is considered a basic part of a health insurance policy. we're not saying we're eliminating the private sector. we're not saying -- we're not going to the v.a. model or the medicare model even. this is -- this is a reasonable, modest, should be widely supported on a bipartisan basis ideas that have come over the years from democrats and republicans, and yet we still get arguments that are wholly and completely protecting the interests of an industry that we are, in fact, trying toen gauge in providing affordable health care insurance. mr. whitehouse: and a little competition. mr. baucus: mr. president, who has the floor?

we all three do. the presiding officer: the senator from montana is recognized, and the colloquy was going on and it was terrific. mr. baucus: i ask my colleagues if -- and either one can answer. in america, although we spend about -- in all of america about about $2.5 trillion on health care, that basically it's 50-50. i think it's about had -- 41% or 42% public and 50% private. we in america have roughly a 50-50 system today, is that about right? ms. stabenow: i would say to our distinguished colleague i believe that is the case, and in fact in my state we have 60% in the private market through employers. mr. baucus: so this legislation before us basically retains that current provision? ms. stabenow: yes. mr. baucus: what we're doing is coming up with a uniquely american solution. we're not great britain, we're not france, we're not canada. we're