request on the floor and modify it so there's simply a vote on this second-degree amendment, amendment 2808, immediately before the vote on the mikulski amendment. the presiding officer: is there objection to the request as modified? mr. durbin: mr. president, reserving the right to object. the presiding officer: the senator from illinois. mr. durbin: i'm not sure i would support or oppose the amendment offered by the senator from indiana, but this matter has been on the floor for three days. there is a pending amendment from your side of the aisle from senator mikulski on this issue. i would hope you have approached her to incorporate your language. i don't know if you have approached senator mikulski, but at this point we think we have some effort being made at fairness on both sides, that there will be democratic amendments and republican amendments both offered, mikulski, murkowski and mccain

and bennet, so i would object because i believe we have the basis for a fair agreement at this point. the presiding officer: objection is heard. is there okay to the original request? mr. vitter: mr. president, reserving my right to object. the presiding officer: the senator from louisiana. mr. visitor: again, -- mr. vitter: again, i'm very disappointed to hear that. senator murkowski has incorporated similar language. i was hoping we could come together 100-0 to actually pass this onto the bill whichever alternative tomorrow is voted up and maybe they both will be, but which ever is voted up or which ever is voted down, i think it's very important to come together and state that we don't want these new task force recommendations to have any force and effect, so let me propose a third and final alternative unanimous consent request that at any point after

these votes but before cloture is filed on the pending matter, that this amendment 2808 receive a vote on the senate floor as a first-degree amendment to the underlying bill. mr. durbin: mr. president, reserving the right to object. the presiding officer: the senator from illinois. mr. durbin: may i suggest to my friend from louisiana, would you consider approaching senators mikulski and/or murkowski first thing tomorrow and see if they are prepared to work with you on this? this mikulski amendment has been pending for three days. mr. visitor: mr. president, i -- mr. durbin: then i object. the presiding officer: objection is heard. mr. vitter: mr. president, if i can respond through the chair. i reserve my right to object. the presiding officer: the senator from louisiana. mr. vitter: just so i can respond directly. i department mean to cut the gentleman off. if he has any further statement, i would be happy to listen to it. just so i can respond directly,

i have approached both of those members and everyone involved in this debate first thing today about this language and certainly the majority side has had this language for at least seven and a half hours. the equivalent of this language has been incorporated into the murkowski amendment, but my hope is that the same thing be accepted in the mikulski amendment because it's not clear which is going to be adopted. i don't see the great controversy here, so that was my hope and that's why i had approached those two senators and the majority side seven and a half hours ago about it with specific language. so i'd renew my last unanimous consent request that i made in that spirit. mr. durbin: reserving the right to object, staff advises me that they are reaching out to senator mikulski at this moment, and i

don't know if we can be in contact with her this evening, but i would ask the senator from louisiana if he would consider allowing us to go forward with this unanimous consent request in the hope that we can still modify it tomorrow if there is an agreement with senator mikulski at that point. i don't think that jeopardizes the senator from louisiana's right to offer this at a later time in the course of this debate, and based on that i would continue to object. the presiding officer: objection is heard. is there objection to the original request from the senator from illinois. mr. vitter: mr. president, i reserve my right to object merely to respond through the chair, and i would say i have been working in that spirit. i've given the language to the majority side. i have been working both at the staff level and member level with many folks. this should be noncontroversial. i don't know of any senator who disagrees with this, so i will accept that offer. i will not object to this pending unanimous consent, but i

truly hope that that offer is made in good faith because i believe when anyone reads this language, they will agree with it. it simply says -- again, it simply says that these latest recommendations by the u.s. preventative service task force made two weeks ago will not have any legal force and effect, and i believe all of us -- certainly that's my impression. i guess we'll find out tomorrow morning. i believe all of us want to stop them from having force and effect because it's a great step backward in terms of breast cancer screening and mammography and even education about selfexamination. so i certainly take that offer and look forward to the majority side rereading this language and hopefully accepting it tomorrow morning because i can't imagine substantive grounds for objecting to the language. thank you, mr. president. with that, i will not object.

the presiding officer: without objection, the request from the senator from illinois is agreed to. mr. durbin: i note the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

the presiding officer: the senator from illinois. mr. durbin: i ask unanimous consent the quorum call be suspend. the presiding officer: without objection. mr. durbin: i ask unanimous consent the previous order with respect to h.r. 3590 be modified to amendment that the vitter amendment number 2808 to the mikulski amendment number 271 be agreed to and the motion to reconsider be laid upon the table and that the order be further modified to provide that the vote with respect to the mikulski amendment should now reflect the mikulski amendment as amended.

the presiding officer: without objection. mr. durbin: i ask unanimous consent the senate proceed to a period of morning business with senators permitted to speak for up to ten minutes each. the presiding officer: without objection. mr. durbin: i ask unanimous consent the senate proceed to the immediate consideration of senate resolution 366, submitted earlier today. the presiding officer: the clerk will report. the clerk: senate resolution 3 366, extending condolences to the families of sergeant mark riner, officer teen that griswald, officer ronald owens and officer greg richards. the presiding officer: without objection, the senate will proceed to the measure. mr. durbin: i ask unanimous consent the resolution be agreed to, the preamble be agreed to, the motions to reconsider be laid on the table with no intervening action or debate and any statements related to the resolution be placed in the record at the appropriate place as if read. the presiding officer: without objection.

mr. durbin: mr. president? the presiding officer: the senator from illinois. mr. durbin: i ask unanimous consent that the previous order with respect to h.r. 3590 be modified to provide that the time until 11:45 be equally divided between senator mikulski and the minority leader or his designee. the presiding officer: without objection. mr. durbin: mr. president, thawc that when the senate completes its business today it adjourn until 9:30 a.m. tomorrow, december 3, following the prayer and pledge, journal of proceedings be approved to date, the morning hour be deemed expired, time for the two leaders be reserved for use later in the day and the senate resume consideration of h.r.

3590, the health care reform legislation as provided for under the previous order. the presiding officer: wor witht objection. mr. durbin: there will be a series of two roll call votes at 2:00 245rbgs will be in relation to the mikulski amendment as amended, the murkowski amendment, the bennet of colorado amendment and mccain motion to commit. if there is no further business to come before the senate, i ask that it adjourn under the previous order. the presiding officer: the senate is adjourned

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and explore the history, arts, and architecture of the capital. one of america's most symbolic structures. american icon, a three disc dvd set. it's $24.95 plus shipping and handling. order online at c-span.org/store. >> coming up in just over an hour on c-span 2 des moines house budget director talks about the cost of the house and senate health care bills. after that, house hearing on breast cancer screening recommendation. up next, senate debates on health care costs. will reform mitch mcconnell banking chairman chris dodd finance chairman max baucus and republican unendurable marlet xander. cmac with every passing day, mr. president the american people become more and more perplexed about the democratic land for health care and they like it lots of mice. it meant lowering cost.

this bill actually raises cost. americans thought reform meant helping the economy. this bill actually made it worse. americans thought reform meant strengthening medicare. this bill raised it to create a new government program that will have the same problems that medicare does. americans wanted reform. what they're getting is the opposite. more spending, more debt, more burdens, more families and businesses already struggling just to get by. one of the biggest sources of money to pay for this experiment is medicare. this bill cuts medicare advantage by $120 billion. it cuts hospitals by $135 billion. it cuts home health care by $42 billion. it cuts nursing homes by

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

a vote against the mccain amendment is a vote to raise this final program in order to create another one for an entirely new group of americans. soy vote against the mccain amendment is a vote to take money out of medicare to create a program for an entirely different set of americans. a vote against the mccain amendment is a vote against our seniors. and it is a vote against real health care reform. mr. president, i yield the floor. >> time remains. >> 13.5 minutes. >> let me yield myself five minutes if i may. mr. president, i just want to come back if i can. i want to put up the charts. let's put up these charts. i say this respectfully because i genuinely believe that people

across the spectrum here would like to see some reform in the health care system. the question is whether or not the proposal that has been laid before us by the finance committee and health committee ricciachieves reform. and whether or not it is going to achieve lower costs, greater access, or the quantity of health care. we believe firmly and strongly that it does and outside observers of this process was no political agenda whatsoever but really make the determinations to whether or not the goals that we have thought of this legislation achieves the desired results are there or not. is the conclusion of the major organizations that make these determinations that are in fact we have done exactly what we said we were set out to do. but i want to point out because they're bigots important when i hear the arguments from our friends on the other side of their deep concerns about medicare. it's very very important that they understand that they are -- but over the last number of years we seem quite the opposite

reaction when it comes to the medicare program and our nation. and going back, if you will, to 1995 when our friends took over the control of both his body, the other body, they began a newt gingrich announced to the world that he was prepared to let medicare, and i quote him, whether on the vine. that's not history. that's nearly 15 years ago, 14 years ago when the other party for the first time in 40 years became the dominant party here in congress. one of the first image from the leadership of that party was about this program whether on the vine. again, that's one person, the leader of the revolution that produced the results collected orally and 1994. but i think it's the backdrop of the year debate about medicare is important to have some history, generally speaking. so in 1995 we begin without a

backdrop. in 1997, two years later it happened again. in 1997, if i may, here were the proposals. 1997, medicare funded a penny and proposed the republican balanced budget act together worth twice what we're talking about the savings in the spell. a 12.4% reduction in medicare benefits in 1997. and of course in the last budget, submitted by president bush last year and again i think it is reflective -- this is a year ago. it's not 14 years ago or not 1997, the 2009. the bush administration and its admission of the budget proposed a 481 billion-dollar reduction in medicare benefits. that was not in the context of health care reform bill. that was just in the context of a budget rebozo. we're talking about savings by reducing cost and hospitals and other providers as a way of strengthening medicare,

providing more benefits to the people and beneficiaries themselves, but things like prescription drugs as well as in screenings and early prevention efforts which are included in our bill, which have been identified of course by aarp and the commission to preserve and protect social security and medicaid. they have analyzed our proposals and a suggested we do just that. we strengthen medicare and we preserve those benefits. our bill states $380 billion in order to strengthen the medicare proposal. improves the quality of health care procedures as part of our comprehensive reform. in fact, senator coburn's choice act actually imposes a 40 billion-dollar more cost and medicare advantage than our bill does. so i find it somewhat intriguing that for those who are arguing for the coburn proposal as an alternative and yes i'm intensely suggest not to do anything to medicare advantage have not read the coburn bill because he got $40 billion more out of medicare advantage than

we do in our legislation as proposed. let me just what is icann and conclusion from the national committee reserves social security and medicaid. again, not a organization. their sole mission is to see to it that social security and medicare will be there for the people is intended to support. in a letter sent to every united states senator from the commission, but make what exactly from it. not a single penny of the savings in the senate bill, the bill i propose, well, but the pockets of beneficiaries in the traditional medicare program. i medicare savings included in the house bill, the patient protection affordable care act will positively impact millions of medicare beneficiaries by slowing the rate of increase in out-of-pocket costs and improving benefits and it will extend a sovereignty the medicare trust fund is five years. to us, this is a win-win for seniors and the medicare program, end of quote.

we can hear all the partisan debate back and forth. but if you're just in what those organizations whose sole mission is to analyze whether or not beneficiaries are going to be advantaged or disadvantaged by what is being proposed here. they unequivocally propose that mccain amendment would do just the opposite. it would roll the clock back by reducing or eliminating the provisions included in our bill and they strongly support the finance committee wrote in its bill it is now presented to all of us here at the way to strengthen and preserve the medicare program. and so i say to my colleagues into the others, you can listen to this partisan debate back and forth as to whether or not to want to believe the democrats or republicans, but i would suggest if you're not going to believe, listen to the organization whose job it is to protect this program, with whom we have worked very closely to determine that we would not in any way reduce those guaranteed benefits

senator baucus just address. that is what we do. that's why it is a good bill and deserving of our support. i urge my colleagues to reject the mccain amendment. mr. president, i yield the floor. >> senator from montana. >> mr. president, the republican leader just a few moments ago says that this bill raises cost. with all due respect, my good friend from kentucky's statement is false. just as we do nonpartisan congressional budget office found the organization that analyzes legislation, both sides, both bodies depend on it. and be very professional outfit i might add that at our bill would reduce premiums, not increase, but reduce premiums

for 93% of americans. it would make sure that better quality insurance is available. let's take that a little bit differently. the cbo said that 92% of americans premiums would be reduced. it is true that for those that is not the case those americans whose incomes are too high to qualify for subsidies, that is the tax credit by an assurance in exchange. but those 7% would get a lot better insurance. a lot higher quality insurance, then they get today because of their insurance market reforms in this legislation. the provisions which deny to exist preexisting conditions health status the community through the market rating provisions as the recession,

etc. so for all americans, it is true that this legislation can provide better quality insurance comparing apples with apples. 92% reduction for all americans. 93% and the other 7% will be the individual marketers. they will have a lot higher quality insurance and in fact it would exceed the increase in premiums to give them a better deal than they otherwise would be getting. they looked at this for the year 2016. but at least it is the case for 2016. in fact, for many in the nongroup markets, those individuals who buy insurance, they would find that their premiums would be reduced about 40% or 50%, that's about 60% of those nongroup market with

insurance premiums that would be reduced -- i don't have the exact figures in front of me. but it's in the neighbor heard of 40% or 50%. due to tax credits. and cbo says that both tax credits would cover nearly two thirds of premiums. so i guess that's a little conservative. two thirds of premiums. cbo says that those tax credits would pay roughly 56% to 59% lower premiums than they would get in our deal. and those are real savings, mr. president. what about out-of-pocket costs? this legislation has absolute limit pocket costs. today the companies can't sell you a policy to pay certain premiums, but there is no limit on the out-of-pocket cost that

you might have to pay here. your deductible is so high, for example. this legislation puts an absolute limit that no policy could be solved, allows you to out-of-pocket more than a certain amount. i think it's $6000 per individual and double that for a family. but there's a limit that this bill does not devastated by the minority leader of raising cost, in fact it reduces costs. in addition, there are many people who say this is a trillion dollar bill and some say $2.5 trillion bill. senators on the other side of the i'll make this statement. and they say this to try to scare us. i think -- to be honest with you, i don't know if they will believe it. but it is a nice good scare tactic. and i say i'm not sure that i don't believe it. i wonder if they believe it because when you read the

legislation its deficit neutral. we have a bunch of resolution mr. president. under the budget resolution of care legislation for the next ten years has to be deficit neutral. it cannot have one thin dime to the deficit. senator kerry talked about a trillion dollar bill. it doesn't cost anything. in fact, it reduces the deficit to $130 billion in a ten year period. that's what the cbo says for congressional and on budget office. and in the second ten years, cbo says it will reduce the deficit by a quarter of a% from gross domestic product. that's roughly half a trillion dollar spirits on the second ten years this legislation reduces the deficit by half a trillion dollars. that's reduction in deficit. so i don't know why or where, you know, these people say there is a trillion dollar bill. i haven't heard one senator, i actually heard him say it's a

$2.5 trillion bill. i mean, it's not true. just not true. it's not true because it's paid for. now, i can say that something cost something, that it would only be fair if i also say that it's paid for. i think it's fair to give both sides of the story, not just one side of the story. and i'm giving both sides of the story. it does cost a trillion over ten years, but it's paid for. in fact, if more than paid for. and those that say 2.5 trillion started a different age. they started at 214 after the 2020. that's why they say it cost so much. it's paid for during those years, too. so, this bill is to make it very clear here, this bill does not raise cost. it in fact lowers cost. this bill does not add to our

federal deficit. in fact, it reduces our federal deficit. and i would just urge us to look at the facts very closely whenever we hear statements he made by anybody, including myself. i urge people to listen and read between the lines into what's really going on here. as my father used to say a long time ago, it was very wise. he said don't believe everything you read, and only half of which are here. which is take everything with a few grains of salt. if you take everything with a grain of salt, the truth starts to emerge. >> mr. president, i agree with the senator from montana. that's why it's fortunate that we at 22 minutes on the republican side to clear up some misconceptions. the democratic health care bill does cost $2.5 trillion over ten years when it's fully implemented. if i may say so, arrogant to say

that the american people couldn't figure out the difference between the first ten years when the bill wasn't implemented in four of those years. and they'd like to know that it cost $2.5 trillion. >> senator, please field for questions. >> if it's on your time. >> find, is a paid for? >> the senator is right and that's a subject that i would like to talk about. it's paid for by cutting grandma's medicare. it's paid for by letting grandma's medicare by $465 million over a ten year period and the second billion dollars -- >> that's a question i would love to debate with you. but on the first question only, you do admit that it's paid for? >> no, i admit that cost $2.5 trillion in the attempt to pay for it. is medicare cuts and tax increases and increases to the deficits not including the physicians reimbursement in the health care bill. >> if i may ask one more

question. i think that we all know the house is taking action now that this reimbursement. the senate will also take action on it before we adjourn. and that is the so-called dockets six. which is really a separate issue. that was paid for. but putting that aside, just the health care reform. we've always had to say that because they take up the dock 61st ever year. you don't take up health care reform every year. health care reform is an entirely separate proposition , a separate legislative deficit. if the senate will bear with me and take dock fixup table just for a second, we can address that later. just for a second, health care reform is a tenure number and were going to start 2010 or start 2014, whenever you're going to start out it is still either a trillion dollars or 2.5 trillion depending on where you start. without getting into how it's

paid for, is it paid for and therefore it's not deficit? >> i would be glad to concede to the senator from montana that the attempts of the democrats to pay for their $2.5 trillion bill are medicare cuts, tax increases, and additions to the deficits by not including the physicians reimbursement which is the essential part of anything your health care plan. there may be other problems, but those are the three things that i know about. >> one more question on my time. >> fine with me. >> is it true that there are no cuts and guaranteed beneficiary payments? there are no cuts, none whatsoever of guaranteed benefits? >> i would say no to that, mr. president because the director of the congressional budget office made it clear that there would be specific cut benefits for those who have

medicare advantage, which is about one out of five. >> those provisions are not guaranteed provisions. i'm talking about guaranteed benefits that people and seniors expect to get when they go to the doctor. the expected benefits they expect to get under ordinary medicare, not benefits of the private plan any addition might pay. >> well, mr. president, in response to the senator, it is clear that they are $465 million in cuts in medicare, the president come the senator from montana, all of us agree that talk of how the bills are a good part of how the bills is supposedly paid for. and it's specific enough to say that $135 billion come from hospitals. 120 billion for medicare advantage, which 11 million seniors have. nearly $15 billion from nursing homes. a billion dollars from hospices. that's the block is bill that

came from the finance committee and this bill is not that much different. and the director of the congressional budget office testified that provisions like that would result in specific cuts to benefit for medicare advantage. he said that fully half of the benefits currently provided to seniors under medicare advantage would disappear. the changes would reduce the extra benefits such as dental, vision, hearing, coverage that would be made available to beneficiaries. >> one more question. does the senator agreed that this legislation will expand the medicare trust fund for five years and failure to pass this would mean insolvency that the trust fund would not be extended for five years? >> mr. president, i would wholeheartedly disagree with that assertion. it said that between 2015 and 2017 medicare will be approaching insolvency.

and they asked that we take urgent action. and the urgent action recommended that a democratic majority is that we take 465 billion out of the medicare program over ten years and spend it on a new entitlement. it's hard for me to understand how that can make medicare more solvent you take money out of ram of medicare and spend it on someone else. >> respond to another question. isn't it shall we say enron accounting when you have a proposal that you, as soon as you have the bill become law, you begin to raise taxes and cut benefits and then you wait four years before any of the benefit are then extended to the beneficiaries. that -- back on its face is a remarkable piece of legislation.

my experience, which has only been 20 some years that we haven't passed legislation and those were going to collect taxes on it for four years and then we are going to give you whatever benefit that may accrue from this legislation. there is then no time in history, i would ask my colleague, there's been no time in history where we have taken money from already a failing system to create a new entitlement program. >> which colleague are you asking? >> pardon? >> which colleague are you asking? >> the senator from tennessee. and obviously i was addressing the person who has the floor, which i'm sure that the senator from montana should understand by now. >> well, i was a to the senator from arizona that he is exactly right. or another way to describe it, the senator from kansas said it was like writing a big check on

an overdrawn bank account to buy a big new car. that may be another way, if i could respond to the senator from arizona and i would ask consent that republican senators in our time he allowed to engage in a colloquy. >> mr. president, may ask the senator question. >> i'd like to finish responding to senator mccain if i may. >> than a question on the same subject. >> i hope the department is taking care of the time. i'm enjoying the questions. i think the senator from montana for his question. one of the things that impact i a great complement has been paid is our senator from arizona that in your united states senator could have something he said actually begin to break through the fog and data milbank a very perceptive "washington post" columnist wrote a column today about it's been all about grandma and wondered why we never mentioned grandpa. and maybe mr. milbank hasn't seen the movie the big fat greek

wedding weatherman said i'm the head of the house and the woman said then i'm the neck. because i can turn to hit anyway i want. we're talking about grandma because she cannot persuade grandpa. but the fact of the matter is we take 465 billion over ten years out of medicare, grandma and grandpa and those who are younger who are looking forward to medicare are going to be affected. i wonder if i may say to the senator from arizona and the senator from oklahoma and nebraska here. it wasn't long ago in response to your question. in fact, it was 2005 when her democratic colleagues sought to -- when we sought to restrain the growth of medicare by $10 billion over five years. and this is what they said. now remember their restrain into to both of medicare by 465 billion spending on a new program and republicans were at the time trying to save

$10 billion over five years and a moral document said senator reid, senator dodd, the distinguished senator from connecticut, funding from medicare would be cut. senator rockefeller, a moral disaster of monumental proportion. senator boxer, in the same way compared it to katrina. senator kerry, where passing it on to our seniors. senator levin, will be hurt by this bill. senator reid, senator hillary clinton. mr. president, those first $10 billion to spend it on the existing program, get this proposal by the democrats would take 465 billion spend it on a new program. is that true? >> and and a veteran of the senator from montana is on the floor that he wants to enter in here. maybe you could respond to his comments 14 years ago when we were trying to create a new

retirement program, which is the object of the senator's bill. we were just trying to enact some savings in the medicare system. and so what did senator baucus said? and above all we must i use medicare as a piggy bank. you know, whenever you send $483 billion in cuts in medicare for? and then the senator from montana said come of that is disgraceful. perhaps some changes lie ahead, but if they do, they should be made for the single purpose of keeping medicare services for senior citizens and people with disabilities. now that we are taking 483 alien dollars out of the system that is failing, that the medicare trustees are going to go bankrupt. so the senator from montana 14 years ago alyce said seniors could easily be forced to give up their dock their, as doctors began to refuse medicare patients in hospitals, especially rural hospitals closed. isn't that the effect of taking

$483 billion in cuts in medicare. then the senator from montana went on to say equivalent to blowing up the house and directing a tent where it used to be. well, if that's blowing up a pop tent i would say this is a hydrogen bomb to the senator from montana. and finally, staggering, staggering. and now of course under the senator from montana's bill the leadership now proposes something like $250 billion in medicare cuts. it's staggering. it's a reduction of nearly a quarter in medicare services by the year 2002. we learned a lot over time, a lot of us to learn about the issues. i hope that apparently the senator from montana didn't learn much because he was deeply concerned 14 years ago about very small savings in medicare. now he wants to spend $2.5 trillion, take $483 billion out of medicare to create a new entitlement system. >> minor respond to the senator?

>> the senator from tennessee has the floor. >> i'm happy to see a debate actually break out on the senate floor from this issue. and as long as it's on democratic time. >> here's your chance. >> as long as it's on democratic time that's fine. >> it's both sides, even time. >> whatever time you use should be on democrats. >> well, the basic question here is obviously how to protect medicare benefits. that's the basic question. i would think most of us would agree. how do we protect medicare benefits and how do we extend the solvency of medicare trust fund? i think that's the basic question. and i think we'd all agree that excessive payments to providers would cause the insolvency of the trust fund to come earlier rather than later. i think we all agree that

proposition . next question is what would excessive providers do get providers get paid excessively. that is an honest question we should ask ourselves in a way to help extend the solvency of medicare trust fund. and in fact, in 1995 especially on your side of the aisle did say just that do we have to can't medicare in order to save benefits. that was made by many senators. i've got them right here in front of me if anyone wants to hear it. and that's exactly what we're doing here to this bill. we are trying help extend the insolvency of the american trust fund by cutting down on the excessive provider payment to medicare trust fund. and how do we decide whether the payments are excessive or not? that's the basic question here. and all we can do is just give it our best shot, just make our best judgment.

and i think it makes sense to look at the recommendations by outside independent groups, what they think. and one is medpac, the medicare advisory committee. that outside group advises congress on medicare payments because we're not members of congress, totally competent to know exactly what dollars should go into which industry group. i mean, we've got too many obligations here to think about. but we must responsible as senators to do the best we can. while medpac has said these groups have been overpaid. and wall street analysts tend to agree. in fact, medpac said to medicare advantage that they've been overpaid, i forgot the exact amount, by much less than 118 billion-dollar reduction in this bill. in fact, i total up and looked at the growth rate, projected

growth rate of providers, hospitals, nursing homes, home health, hospice, pharma, you name it. and on average the growth rate is going to be 6.5%. that's a growth rate of providers. if we decide to turn out a little bit. we decided you cannot down by 1.5%, so it's a 5% growth rate for all the industries here. in an attempt to try to find the right level of of reimbursement that trammell also help extend the solvency of medicare and trust fund. and we talked to providers. they basically agree with those cuts. they basically agree -- why did they basically agree? to basically agree because they know with much more coverage and many more people with health insurance they can spread out, you know, their business.

they may lose a little on margin, they can pick up on volume. and that's exactly what their business plan is under this bill. wall street analysts say, and i quote them, is they industries are doing great. they're doing well. they're not getting hurt. so we do achieve a win-win. i don't like that phrase anyways, but i'll use a here. where the solvency of the trust fund is being extended and where the reimbursement rates to providers is fair, not being hurt. it's fair and that's why they want this bill by and large. most groups tend to want this bill enacted because they know it's good for the country. it's good for seniors and that's good for them, too. >> mr. president, could i just mention again, $70 billion with fraud use and waste and senator coburn and the doctor can tell you there's nowhere in this bill. and the fact is maybe some of

the providers have been brought off or give them their selves good deals like pharma has but the recipients haven't. but medicare recipients know that you can't cut $483 billion without ultimately affect them their benefits. and that's a fact. and again, conspicuous by its absence i say to the senator from montana, totally conspicuous by its absence is any meaningful malpractice reform, which has been proven in the state of texas and other states to reduce cost and increase the supply of physicians and caregivers and there's nothing in this bill that's meaningful about medical malpractice reform. i had a town hall meeting with doctors in my state and everyone of them stood up and said, i practice defensive medicine because i fear of being sued here so if you're really serious, i say to the senator from montana, if you're really serious about this, i go malpractice should be a key part

of it. even the cbo cost that at about $50 billion a year and when you look at other defensive medicine that could be as much as $5,200,000,000,000 over ten years. that's conspicuous by its absence. i think it brings into question the dedication of really reducing health care costs across america. >> we've enjoyed our discussion with the chairman of the finance committee. we thank them for us questions. senator coburn who is a physician. the senator from montana has talked about doctors been overpaid. he talked about -- >> no, no, no. with all due respect, i did not say that. >> did i hear the word providers are paid? >> in fact, if i may say to my good friend from tennessee, this legislation pays more to the primary care doctors of the

shed. 10% increase in medicare reimbursement for each of the next five years. and i did not use the word.yours. >> well, providers, mr. president i must've misunderstood because normally we talk about providers we talk about hospitals and physicians. but we have a physician on the senate floor. the senator from oklahoma. and i wonder if he having heard this debate might want to comment. and they might say, isn't it true that the mccain amendment, which we have on the floor would send this back to the finance committee and say if there are savings, let's spend it on medicare to actually strengthen it. >> well, i think the senator. the first comment i would have is relying on what a wall street analyst says today. they have about this much credibility in this country today. look at the economic situation we find ourselves than because of what wall street analysts have said. that's the first point i would make. the second point is the majority win yesterday says we should not

cut medicare. we should cut medicare advantage because of the 14%. senator dodd just recently went after the patient's choice act as we actually make it be competitively bid without any reduction in benefits. your bill, for every medicare it, cuts 50% of the benefits out. it cuts the benefits. and so the difference is and i agree with the majority. we do need to have the savings in medicare advantage. but the way you get there is through competitively bidding it, at the same time maintaining the requirements for the benefits that are offered. there is a big difference in the two. hours and i've have been pure savings to save medicare. the savings in this bill are to create a new entitlement. the other point i make. if you're a senior out there listening and if you're going to be subject to the new increase in medicare tax, for the first time in history, we are going to take medicare taxes and not use

it for medicare. we are going to use it for something else. under this bill, this .5% is now going to be consumed in something outside of medicare. so no longer do we have a medicare tax for the medicare trust fund, we have a medicare tax that funds medicare trust fund plus other programs. i would say to my colleagues, i think we want a lot of the same things. how we go about it, the senator from montana recognized the fact that we are going to increase payments to primary care physicians. ask yourself the question why only one in 50 doctors last year who graduated from medical school is going into primary care. why do you think that is lax could it be that the government who is setting the payment rates created a maldistribution in butyrate into primary care

physicians. therefore, they choose to go where they can make 200% more over their lifetime by spending one additional year and residency rather than doing primary care. and what this bill does, and what the senator from arizona is trying to do by sending this bill back is to refocus it on the fact that medicare money out to be used for medicare. and if in fact we're going to slow the growth of medicare, can we do that without cutting benefits? and to slow the growth in this bill for 11 million americans who now have medicare advantage. he will diminish their benefits. that's out of the 120 billion that's going to come. you can't tell a senior who's in a rural area today who is on the economic lower rungs of the ladder he uses medicare advantage to equalize their care to some of you can afford a medicare supplemental policy. you can't tell them that this is not going to decrease their

benefits and decrease their care because it is. and in the bill actually states that it's going to decrease their benefits. >> also very briefly, the senator from montana talked about the support that it got -- dedicate a r. p. aarp makes more money for medicare than they give to seniors. other senior groups like 60 plus or educating seniors. ama endorsement of the bill, the bill puts the government in charge but ama cut a build to get their medicare payments addressed by increasing the deficit by $250 billion. and farmout, my god if there's ever an obscene alliance that would harm seniors because it prohibits -- it has the administration against canada competition for medicare.

so we need to understand a little bit better why the special interest groups, 500 some of them, have visited the white house in recent months according to white house for loss. >> the senator would be interested to know in my colleagues on the other side, the ama now represents more than 10% of the actively positions. the positions as a whole are adamantly, adamantly opposed to this bill. and the reason they're opposed to this bill is because you are inserting the government between them and their patients. that's why they're opposed to this bill. so you have the endorsement of the ama, which represents less than 10% of the practicing doc airs, actively practicing doctors in this country because not only will it increase payments, but cpt cobra been protected. it's ama gathers from the payment system that continues to be fostered in this bill. it's their main source of

revenue. >> can i ask my colleagues indulgence for just a moment because as you know, the majority leader seems to appear more and more frantic as he perhaps his reasoning the same polls that we are that more and more americans when they figure out this legislation are becoming more and more opposed to it. so yesterday the majority leader came out and directly addressed me, saying quote, this man talks about earmarks but his amendment is one big earmark to the insurance industry and in addition to that sponsored the amendment, talking about me, during his presidential campaign talked about cutting these monies and, you know, i hate to -- i say to my colleagues take a trip down memory lane. but at the time, and this of course was then echoed by dnc spokesperson who then upload it throughout the blogosphere and the left-wing liberal blogs. and the fact is that on

october 20, fact check.org says he accuses mccain of cutting benefits. this is fact check.org. tbn speeches making bogus claims that mccain tends to cut $800 million reduce benefit. booktv spot a very well campaign not says mccain's plan requires cuts in benefits eligibility or both. obama said in a speech that mccain plans cuts that would force seniors to pay more for your drugs, receive fewer services and get lower quality care. second ad claims that mccain's plan would bring about a 22% cut in benefits, etc. and the fact check.org says quote, these claims are false a sunny single report that says no such thing. mccain's policy director states unequivocally that no benefit cuts are envisioned.

mr. president, i ask that this entire fact check.org article be included in the record and i hope that the senator from nevada was not making false claims about repeating the false claims that were in attack ads on me throughout the campaign funded by tens of million dollars about my positions on health care in america, which the fact checkers have found to be totally false. and the narrator says mccain's plan means that 22% cut in benefits, the ad displays a footnote display in an october 6 "washington journal" story as its authority. factcheck.org says but in fact the journal story makes no mention of any 22% reduction or any reduction at all. so i hope that among other things may i describe this frustration that the senate majority leader would at least

not repeat false accusations about what i wanted to do in the presidential campaign. and it's unfortunate. i hope that maybe instead of attacking david broder. instead of attacking me, instead of attacking others who are in support of this amendment, maybe we could have a more meaningful discussion about the facts that are surrounding this legislation. >> to both sides. >> thirty seconds remaining. >> for which side? >> for the minority. >> a minority have 30 seconds? >> i will speak very quickly since we have 30 seconds. reality just set in. we have looked at the impact of these ads on our nursing home beds in nebraska. we have about 14,000 bed dedicated to medicare. this will be a loss of $663 per

bed. that affects real people. thank you, mr. president. >> you may yield two minutes of our time to my distinguished colleague. >> very kind of you and i appreciate that. mr. president, maybe it comes from my time as governor. maybe it comes from my time as a mayor. but somehow, someway you've got to live with the legislation that is passed, whether it's by the federal government, whether it's at the state level or whatever. you can bounce this back and forth all day, but the reality is these are real cuts and they involve real programs that involve real people in our states. you can describe them anywhere you want. you can call them excessive payments. you can do this, that, or the next thing. you can say well, we are giving us our best shot. but the difficulty is this is a high-risk venture. you are impacting in my state,

for example, and every senator could stand up and give the same speech. you are impact teams the most vulnerable population in our nation, people who are in a nursing home that are medicare beneficiaries. as i said in a short statement, there are 14,061 nursing home beds across our state that are dedicated to medicare patients. we are working overtime to try to understand what this legislation does to wear a people. the number that we have, working with our nursing home industry is that if this legislation is passed, each bed is impacted by a loss of $663. i will sum up my comments by reading something that was sent to me by someone who works the nursing home industry. here is what this person says:

for the first time in my career, i am honestly questioning how much longer i can continue. to constantly be up against regulations and funding, when all you want to do is make a difference in someone's life is exhausting, unquote. mr. president, this is a high-risk venture. this shouldn't be about taking our best shot. this should be about getting this legislation rights. thank you. >> senator from connecticut. >> district president, if i can let me address a couple points. i said this yesterday but it needs to be repeated. somehow this bill doesn't provide any benefits until your 2014 is just untrue. i can spend the next 40 minutes describing the various things that our bill does immediately. on the enactment of this

legislation, there tax breaks immediately for small businesses that will recruit the health care were small business based on average 18% more for health care premiums and other businesses do. as pointed out by the cbo on our bill you're actually seen premium cost reduction in the small-business market as well as the individual markets in the large group markets. our legislation provides immediately a closing good part of that donut hole, which is the immediate benefit for prescription drugs for the elderly. that does not mean four or five years after now that means immediately. we start immediately. as i mentioned earlier, that is not only the humane thing to do, it's also a great cost saver. if you can identify and detect an early problem and deal with it, the cost savings are monumental. we all know that. under our health care plans, as we have as united states senators, were we get 23 different options every or to choose from, we have that benefit. i'm a beneficiary of that

benefits, have identified a health care problem early through screening. that was only beneficial to me personally because i'm going to be alive for a longer period of time than otherwise, but if you thousands of dollars in long-term medical costs if i had not identified the problem. those are simple things that are included in our bill that happened immediately. you can be dropped by your health care carrier as you are today. you can be dropped for no cause for no reason whatsoever. that is stopped immediately on the adoption of this legislation. so when i heard my good friend from arizona so they are no benefits in his bill until three, four, five years, that is just not true. and a simple reading of the legislation would identify any number, a long list i have a benefits have been immediately. the issue that senator baucus has raised over and over again in future guaranteed benefits under medicaid, guaranteed benefits. when you challenge my colleagues to identify a single guaranteed benefit under medicare that is cut by the bill before us.

there is not a single benefit under the guarantee programs that is anyway disadvantaged or reduced as a result of this legislation. what is cut is our health care plans and this is the reason why we are doing this. i do care damage over payments cost everything your more money. a typical elderly couple pays $90 more per year in part b premiums to pay for the medicare advantage over payments, even if they're not in these plans. that's $90 on average for every couple and you get none of the benefits from it. fully 78% of beneficiaries are forced to pay higher premiums for non-medicare extra benefit they will never see. now again i understand that some people apply to have these additional benefits. i understand that. they're not guaranteed medicare benefits. these are benefits provided for under medicare advantage.

by 70% of our elderly are paying higher premiums so the smaller percentage of people can get those benefits. why should 78% of the elderly in this country pay a higher premium? for a smaller percentage of people under private health care plans. what senator baucus and the finance committee are trained to do is reduce those costs. those are not guaranteed medicare benefits. there is no guaranteed medicare benefit that is caught under this bill. and i defy any member of this body to find one guaranteed benefit that's reduced under this plan. i'd be happy to yield to my friend. >> out off the distinguished member from connecticut that we empower the independent medicare advisory ward to come up with $23.4 billion for the cuts in medicare. can the gentleman from connecticut to assure me that the independent medicare advisory board would not find a benefit that they would suggest cutting. >> absolutely, that's allowed under this. you cannot cut benefits.

>> with the gentleman yield for an additional question. is this board empowered? to find $23.4 billion worth of cuts? >> not under guaranteed benefits. and that's very clear. let me point out the board is prohibited, forbidden from proposing changes to take benefits away her and seniors or increase their costs. the proposals cannot ration care, raise taxes, or part b premiums or change medicare benefits, eligibility, or court sharing standards. couldn't be more clear. couldn't be more clear. they are actually prohibited from doing that. and that's a point we've been trying to make here. going up for providers frankly as we know hospitals will play themselves, in many cases, as a provider, there are cost savings. i'm told and again my colleagues who know more about these details than i do. i'm told that it's not uncommon for an elderly person to leave a hospital and on average being

given for prescription drugs in order for them to take your template is well within a month or so that average couple is not following their prescriptions very well. either they live alone or they're not worthy and have been written in. there's a very high readmit and race in hospitals, that's reason the cost for hospitalization. our bill makes significant efforts to stop the problem of readmissions into hospitals which raise cost immensely. that's where the savings are coming here by taking steps to try and reduce the readmission rate as a provider in the hospitals. but they cost savings. that's not denying a benefit to the elderly. it's trying to find money to save their lives. that's a were trying to achieve here. but again i challenge any member to come up and identify a single guaranteed benefit under medicare that is cut in this bill. there are none. in 78% of our elderly should not be required to pay additional

premiums to take care of a handful of other people out there. i understand why they want these benefits and they should not be denied if they want to pay for them, but don't charge the other medicare beneficiaries are the benefit they never gets. i'd be happy to yield to my colleague. >> the mccain amendment, the first item on the first line of the mccain amendment on a motion to permit relates to medicare advantage. i used to work for an old fellow in illinois politics named cecil party and cecil party set for everything in politics there's a good reason and a real reason. we hear a lot is good reasons for the future of medicare. the first reason is on the first line of mccain's motion to commit. and he's sms back to the committee and don't touch medicare advantage. and i want to let the senator from the netiquette about medicare. because some of things i've read about medicare advantage, and that this plan run by private health insurance companies costs

more than basic medicare. these companies promised as that when they got involved it shows how to run a health insurance plan. it shows how to provide medicare benefits and they would save us money. in someúss@@@@@)8zza'";)8zzbh))

it is neither medicare nor an advantage. advantage. >> you are talking about misbranding. it is neither medicare nor advantage, quite the opposite in fact and i want people to noeth as much as we respect our colleague from illinois the numbers he identifies of $100 billion it that is costing in this program, it comes from the congressional budget office. that is the cost savings by modifying this program that has cost us so much, deprive the overwhelming majority, the benefits they get their costs so i appreciate very much the question. >> is it also true that the june medpac reports that medicare advantage over payments cost taxpayers an extra $12 billion? >> that is correct and again that is medpac. >> that is right, that is medpac and the point that he

is making, it needs to underline that two or three or four times here and you have made it too senator dodd and that is there is a huge distinction for medicare and these private insurance plans. >> i think to many of our private citizens here the word medicare advantage. >> they assume it and it is not. it is a private plan. what medicare advantage is overpaying, these insurance companies are overpaid and that goes back to the part-b-- par d drug bill and so forth. the question is, they are overpaid with, to those overpayments necessarily mean a better benefit for persons who signed up for the plants? >> in fact there is no evidence that overpayment in plan leads to better health care. >> i think that is true but why might that be the case? >> coast insurers are not singers or the medicare, too

often they are used to line their pockets. and not provide the benefits to the people who are getting at. >> is that medicare that the sides with the benefits will be? >> no, it is not. >> it is the private insurance company. >> the private carriers are the ones who determine where the profits go and that is why it is such a misnomer to call this medicare advantage. it is anything but medicare or an advantage. >> the time has expired. >> i would ask for two additional minutes. >> is there objection? >> reserving the right to object. >> who get, you get too. in fact. i have no problem. >> you said it is worth repeating, it is about-- >> without objection the request is agreed to. >> most seniors as part b premiums under fee-for-service don't get any benefits

whatsoever. >> that is right, none whatsoever and in fact all they do get is higher premiums. 78% are paying more for a program they never get any benefit from. >> i figured it was $90 a year they pay ekstrand get no benefit. >> vote for the mccain amendment and the preserve medicare advantage comment neidert rediker nord fiennes 70% of our elderly pay more premiums and the private carriers get the pocket the difference. that is a great voter around here. that is great health care reform. >> could be characterized this as an earmark? >> it is two years. i will give it two years. >> we remember ten years ago when the insurance companies came to the government and said we can do something later, we can do it a less-expensive way. the axis that we could do it for 5% less than the cost of medicare and government unfortunately made the agreement is signed up to do that.

denial then what happened in the last ten years the insurance lobbyists came here and lobby the bush administration and lobby the congress and got bigger and bigger payments and it really is a subsidy for the insurance companies but you say it is not medicare. it is a privatized form of medicare that serves the insurance companies very well thank you but does not serve the seniors of this country. >> i will sit here all day waiting for somebody to identify a single benefit under our bill. they are all talking about medicare advantage, not medicare and there are no medicaid benefit send narcan does ben the kids-- in-band semper habits any cuts in benefits. >> mr. president. i have six unanimous consent request bearing today's recession and the senate approved by the minority leaders and ask unanimous consent they be agreed to and be printed and the record. >> without objection.

>> mr. president? >> the senator from oklahoma. >> one of the questions and one of the problems was if you have now and you like you can keep it. what is happening under this bill for 11 million seniors on medicare advantage is not going to happen. if they like it they are not going to be able to keep what they have. you cannot deny it. mccarrick than it needs to be reformed. there is no question about it. i agree with it and as the senate served alluded to the patient's choice act, we actually save $160 billion in the patient's choice fact that we don't diminish any of the benefits and we do that because cms failed to bid it because when it was written and i understand you wrote it, when it was written we did that not make them competitive lee bidded so you can get the same savings, actually you can get more savings and not reduce benefits in any amount if you competitively bid that product but we have decided we are not going to do that.

the second one that would make, the vast majority people on medicare advantage are on the bottom of the economics. they cannot afford and the aarp supplemental build. they can afford to pay an extra 150 or $200 a month so what most of the time happens with medicare advantage is we bring people up to what everybody else in medicare gets because most people can afford, 84% of the people in this country can afford to buy medicare supplement the policy because medicare doesn't cover everything, so your idea to try to save money i agree with. by cutting the benefits, i don't agree with that and you are right senator dodd, the basic guaranteed benefits have to be supplied in medicare advantage and then the things above that which you get with a supplemental policy and which you can afford to vies with these people get. what you are taking away from the poorest of our elderly is

the ability to have the same care that people who can afford to buy supplemental policy. that is the difference, thank you and i do appreciate my chairman for his courtesy. >> this senate has started debate on the health care bill. majority leader harry reid has warned senators to expect evening and weekend sessions. see it all live here on c-span2, the only network with a full debate, on edited and commercial free. the u.s. senate continues work on health care legislation. tomorrow they will vote on a number of amendments. maryland democrat barbara mikulski and alaska senator lisa murkowski have a amendment on women's health care screening services. senator john mccain has a motion to send the bill back to the finance committee to remove medicare reductions. the senate returns at 9:30.

watch live coverage on c-span2. >> now white house budget director peter orszag talk to reporters about the cost of the house and senate health care legislation. from the national press club, this is about one hour. [inaudible conversations] >> good morning and welcome. i am susan dentzer, editor and chief of their affairs and we are happy to be sponsoring this breakfast this morning. we inherited this breakfast from the so-called brosda health

breakfast reporter's group, and named in honor of jerry brosda hill unfortunately left's earlier this year having passed away. i thought it would be appropriate, since jerry started his breakfast, largely because believe it or not once upon a time health policy was the real backwater issue and it never came up in the major news conferences in washington and jerry that thought that was a darned shame. also we found in a rare moments when health policy did serve as as a major issue at say the sperling breakfast he couldn't get in because he was just the blausey helped reporter and of course in those days health reporter's got no respect. so jerry started the brosda breakfast group. many people here today are members of that group and i thought it would be inappropriate to take about 20 seconds which is about as much as jerry would tolerate just in a moment of silence to remember jerry brosda who did so much for

the health policy reporting in this town. and as i say at that point jerry would say come on, let's get going with the question so jerry we miss you and we are honored to be falling in your footsteps today. i have the pleasure this morning of introducing our guest, peter orszag who all of you know is the director of the office of management and budget at the obama administration over sync budget policy, coordinating the implementation of major policy initiatives to the government and of course most particularly at the moment helping to shepherd through health care reform. from january 2002 november 2008 as you will also know he served as director of the congressional budget office supervise an ad agency's work in the analyses of the economic and budgetary issues. before that, he was the joe peckman senior fellow at deputy director of the economic studies at the brookings institution,

also served as director of the hamilton project, director of retirement security project and co-director of the tax policy center. during the clinton administration's he was the special assistant to the president for economic policy and before that he staffed an economist and senior adviser and senior economist at the council of economic advisers. he is a summa cum laude graduate in economics from princeton and holds a ph.d. in economics from the london school of economics which he intended-- attended as a marshall scholar and the author of numerous books and a member of the institute of medicine of the national academy of sciences. finally is also an avid runner had and has completed several marathons. the current one i think qualifying as one of lead push towards health care reform so join me this morning in welcoming peter orszag. >> thank you susan, thank you alper coke it is a pleasure to be here.

i am particularly and thank you for joining us. i want to reserve most of the time for your questions. we stand on the verge of a dramatic accomplishment, not only meeting the moral imperative of the world's leading economic power, dramatically reducing the ranks of its uninsured, not only doing so in a fiscally responsible way, but also putting in place the key tools that will help to lead to the health care system of the future, and biting continuous improvement and an emphasis on quality rather than quantity. two weeks ago 23 eminent economists, including the official who ran medicare under the bush administration, two nobel prize winners and particularly warm to my heart, to distinguished former directors of the congressional budget office sent a letter to

the president outlining the four key pillars of a fiscally responsible health reform and i have the letter here with me. those four pillars are first, the deficit neutrality as gord by the congressional budget office so that the very worst you are doing no harm if the doing no harm to our fiscal outlook. bad second, the inclusion of an excise tax on high-cost private insurance plans, which according to these economists will quote felker till the growth of private health insurance premiums by creating incentives to limit the cost of plans to lay taxfree amount. in addition as employers and health plans redesign their benefits to reduce health care premiums cash wages will increase. the third pillar of a fiscally responsible health reform according to these eminent economists is the inclusion of a medicare commission which would create a process through which

medicare policy cannot adopt to changing conditions more quickly than the current system and as the economist no and i gann will quote, creating such a commission will make sure reforming the health care system does not end with this legislation but continues in future decades with new efforts to improve quality and contain costs. and then finally the fourth pillar of what of a fiscally responsible health reform is a series of delivery system reforms and within that category, i think once you think of several subcomponents. the first is that we need to digitize the health care system because unlike other sectors, the benefits of i.t. have not spread as universally through the health system as in other parts of our economy. as many of you know the recovery act that was signed earlier this year provides an historic level of funding to expand health

information technology and the administration will be coming forthwith regulations so that in the near future, so that money will start flowing and we will be moving towards the digitize system of the future. the second thing in falls comparative effectiveness research, that is research into what works and what doesn't. to much of the health care services delivered in the united states are not backed by evidence that the work better than an alternative and in too many cases your doctor doesn't have the information necessary to evaluate whether this course of treatment or that course of treatment would be more beneficial. again the recovery act included some historic funding in comparative effectiveness research and i will return in a moment to the fact that the legislation under consideration adds upon that. and then finally digitize health care system, research into what works and what doesn't and reorienting the payment system away from paying for more stuff and towards paying for better

stuff. right now we have incentives for volume and that is what we get. we need incentives for quality so that we can move towards a system that emphasizes making people better rather than having more things done. there are a whole variety of reforms that have been suggested in this area, bundled payments, policies and readmission rates, accountable care organizations and what have you but the point is that within that delivery system reform you want a continuous feedback loop with digitized records, evaluation of what is working and what is not and incentives for providers to follow an emphasis on quality rather than intensity. now let's take a look at the senate bill, the bill that is on the floor of the united states senate and a villie wade yet diggins those four pillars that have been put forward by the team of economists. first, not only does the bill to

achieve deficit neutrality according to the congressional budget office, it is better than that. the congressional budget office suggested it will reduce the federal deficit by $130 billion a quarter% of gdp or more than $500 billion over the second decade of its existence so with regard to the first pillar, check that. second, and excise tax. as you well know the bill on the senate floor includes an excise tax on high-cost private insurance plans. check that box. medicare commission is also there, check that box. finally on delivery system reforms the senate bill includes new provisions and bundling with, in avoidable readmissions to hospitals, that is roughly 20% of medicare beneficiaries are readmitted to the hospital within one month of having been discharged from hospital. no one would ever want to have to go back to the hospital with that is avoidable because it is

not a pleasant experience in the senate bill includes incentives to try to mitigate that tendency. it also includes incentives to reduce hospital acquired infections, to promote comparative effectiveness research including to a new nonprofit institute, to promote quality measurement, to create a system to pay hospitals based on value rather than just based on how, on intensity, on volume. to encourage doctors and patients had to engage in more shared decision-making and to create accountable care organizations which have been promoted by a variety of health policy analyst and perhaps just as importantly as it creates a new center that will allow the testing out of a variety of different approaches and then moving to scale as one who learns what works and what doesn't. now i should say it would have

been a lot easier just to do a deficit-neutral build with some savings that are stored by the congressional budget office endic coverage expansion but that would perpetuate a system in which there is inadequate attention to quality and which you are not dealing with these delivery system reforms. that was not the course that the president chose end it is not the course that he did the house of the senate shows so it is worth pausing in just remarking that it would have been easier just to do a blunt savings and coverage expansion bill. that is not what is happening here. now, there have been critiques that have been put forward and let me just try to address the main critiques. the first is that it is nice that on paper the bill is deficit-neutral but come on, we all know none of that will actually transpire in the future and therefore while that looks like it is deficit-neutral or even deficit reducing that is

not the weight is going to be part of the example that is sometimes used is the so-called sustainable growth rate formula which was put in place in the late 1990's and in which congress has regularly acted to prevent reductions that were scheduled to occur. let me tell you why i think that line of argument is not apt to the bills that are currently being discussed. first, unlike the sustainable growth rate formula-- first the fact of the matter is that history is not right. if you look it the savings that have been done in the past including to the balanced budget agreement in the 1990's the vast bulk of them actually were implemented as opposed to being undone. specifically with regard to the sustainable growth rate formula there are significant differences between that and the bills under discussion. if all the bills did was to reduce, to have a gross cap on

payments and not get the underlying drivers of health care costs, then perhaps the analogy would have a more force. that is not what has occurred. elegant as i already said the bills are trying to get that those underlying drivers of health care costs through all the steps we have been discussing. second the existence of the medicare commission which i have already mentioned provides a strong counterweight to any forces to listen in the future. in other words the medicare commission is always going to be putting forward proposals to improve quality and reduce costs over time and that provides a very strong counterweight. finally, don't forget that unlike what has occurred over the past several years in the early 2000's, we now have paygo provisions that are enforced and that are being obey in the house and senate. if you wanted to undo legislation that was enacted this year in the future, under

the paygo rules he would have to offset the cost of doing so and that was not the case as surpluses emerged in the late 1990's and early 2000's and those rules were largely ignored. the second critique is that the delivery system reforms although they are there are too timid, that they are a bunch of pilot projects and they are not going to scale immediately so ironically on the one hand some people are saying there's too much being done and on the other hand others are saying the reforms are too timid. i think one needs to remember that because we have not put as much attention on cost containment in the past or sufficient attention, we don't know exactly how to create the proper financial incentives to reduce readmissions, unnecessary hospital readmissions or to bundled payments. exactly which conditions should be covered, how should the

payment structure work or with regard to accountable care organizations again exactly the parameters that should apply and you can keep going down the list. the problem is that given the lack of attention to this key problem, rising health care costs and inadequate attention to quality in the past we don't know enough to move to scale immediately so in the end it is also worth pointing out the health care market is dynamic. even if we knew a lot now we would want a system in which you are trying things and then you have a mechanism in place to move to scale as you were learning what works and what doesn't. in the senate bill gives you that mechanism where you can go out and try bundled payments. you can try incentives for quality and a whole variety of other things and as you learn exactly what is working and what is not you go to scale through a process that is already embedded in the legislation so what you

are creating is an infrastructure for continuous improvement were again, you have the digitize health care system, research into what is working and what is not in with regard to the incentive payments for providers towards quality you are trying lots of things and you have an ability to get that into practice and into policy much more quickly and adeptly than under current law. so, the bottom line, there is always more work that can be done and although all four of those buckets are checked in the senate bill and undoubtedly there is even more that can be done as this legislation moves forward to strengthen the provisions in each of those four buckets, but the bottom line is the bill that is currently on the senate floor contains more cost containment and delivery system reforms in its current form then any bill that has ever been considered on the senate floor period.

as the debate moves forward we need to continue to keep our eye on those four pillars of the fiscally responsible health reform but i'm confident we are going to get there and that would be delighted to take your questions. thank you very much. >> thank you very much peter. i will take a moderator's prerogative of asking the first question and then we will take questions from all of you and the audience. please be prepared to identify yourself so we can make sure your last name is not salahi. peter, back to the four pillars for a moment, the deficit reduction when you said being the first. a number have pointed out that a lot of the deficit reduction comes about initially the class act provisions in the bill, the community living assistance supports and services which essentially creates this long-term care benefit, collects a lot more money up front rather than paying it out, and really

amounts to a new entitlement being seated within the structure which over time could be much more expensive than we anticipate. how do you you respond to that critique? >> in several ways. first it is not most. it is about half or so of the first decade surplus from the legislation, about 70 billion out of the 130 billion deficit reduction is coming from the class act in the senate bill which means apart from the class that there is a surplus contained in the senate bill. second, even including the class act and the other provisions as the go into the second decade you are still running a significant surplus and then finally there are a variety of provisions within the class act that are being evaluated to try to make sure that even within that program, actuary solvency is assured and the program is on a sound financial footing,

self-contained, and so again bottom line, even apart from the class that the bill is running a surplus and then there are a variety of tweaks that are being explored to make sure that the class act is on a firm financial footing on its own 2 feet. >> what's tweaks would accomplish that? >> i don't want to get into the specific details but there were already changes that were introduced in the version that was embodied in the house legislation. there are ongoing discussions about other things that can be done. i think there is attention being paid to making sure that this program, the class act, can stand on its own 2 feet. >> alright let's take questions from those of you in the audience and begin please identify yourself. >> two questions. first dr. marcia angell former

editor-in-chief of the new england journal of medicine said single-payer national health insurance is the only reform that covers everyone and controls cost in she is now under the belief the legislation going through congress is should be defeated and we should start from scratch. the second question is the ap reported earlier this week that lobbyists, health care lobbyists to the white house repeatedly over the last year, and he met with the lobbyists from blue cross blue shield association in march, and single-payer advocates have been pretty much -- knot of decision-makers like yourself so to questions, marsha angel's single-payer question and second what was discussed with the blue cross blue shield association when he met with them? >> let me deal with those in reverse order. first, in regard to not only with regard to myself that the administration officials writ large, i meet with a whole

variety of folks to know about the health care system whether it is union leaders or providers, insurers, what have you. i am not aware of meeting requests from your group or from others but the key point is that we are hearing from a whole variety of people and institutions that have interest in health care reform and that is exactly how it should be, which is getting a broad view, sort of 360-degree perspective on health care reform. now with regard to-- the bottom line part of your question is, is this bill better than nothing? that is a judgment upon which i come down very firmly on the other side and for reasons i have already discussed, not only are you reducing the rate of the uninsured by 30 million, let's not forget there if more than 30 million americans will have

health insurance in 2015 or 2016 because of this legislation that would not have health insurance otherwise and there are millions more who have higher quality and better insurance with better protection than under current law. than don't forget going without insurance is a key driver of personal bankruptcy and your bearing of lot of risk when you don't have insurance. again, you are not only expanded coverage but you're also doing doing so in a way that reduces the deficit, and put in place by our dimension a whole series of tools that will help lead to quality and reduce costs over time. now, there are some who would prefer not having a mixed public-private system as we have in the united states. i think the president was very clear that we have an american system and that we are going to have a mix of public and private provision and insurance, just

from -- even from a practical perspective. and i think that's where we are. we're on the verge of a substantial of congressman. i would also point out, there has been a lot of attention paid to a public option. and that is understandable. understandable. i would just note i think there was a very good op-ed written by a starr, professor at princeton who had been involved in the effort in the 1990's and co-founded american prospect, pointing out that if anything the attention paid to a public option has been disproportionate to the impact of the fourth example of the regulations surrounding the exchange would help to promote competition and reduce cost. so the public discussion has become somewhat lopsided in his opinion and i happen to agree relative to other things in addition to the ones i mentioned that will help expand coverage, increase competition and reduce

cost. >> let's take another question here. >> thanks. im ifill galewitz with kaiser health news. one criticism from the health industry is the individual mandate and relatively weak penalties, $95 the first year, 750 after two years. why would somebody spent thousands for health insurance as opposed to paying a penalty and one that lead to people waiting until they get sick and then buying insurance? >> well, first one of the things i've learned is that the econ 101 approach to life where all that matters is the direct financial incentive for penalty is just wrong. so, looking at things slowly in terms of the financial penalty, not to say that it doesn't matter but exclusive focus on rational perfectly optimizing behavior is just not where it's

at. if you look at massachusetts for example where the penalty is only slightly higher than $750, they have had, if anything, much more dramatic take up than anyone predicted and that is because, i mean i think it was more important that they were advertising at fenway park than the penalty was 900 or 1,000 or $1,100 the reason is they created a social norm that you were expected to have that everyone knew about and you were expected to have insurance. similarly in other areas if you look at, for example, the difference between adherence to seatbelt laws and speeding always, i don't know what your experience is like -- i would point out by the way if anything the financial penalty for the -- the financial penalties are roughly the same, the amount you get charged for a ticket for not wearing your seat belt or speeding, roughly the same. i don't know about your experience. my experience is that he rents to seat belt use is much more

higher than adherence to speeding laws, and that is because i think there has developed in the united states a social norm that you're supposed to wear your seat belt if you're driving a car or are in a car. if he got and a car and driver was speeding maybe 20 or 30 miles per hour over may be but 5 miles our you probably wouldn't say anything. if the driver were not wearing a seatbelt some of you would say something and that is the important point. a lot of what the impact of the mandate and other provisions will depend on the house social norms develop and on execution. and i probably should have said that at the beginning. one cannot expand coverage by 30 million, move toward higher quality, reduce cost just through legislation, snap your fingers in your done. a huge amount will depend on how well this is executed and implemented. and a lot of attention will have to be paid in the next few years to getting this done right.

>> question here in the front >> maureen groppe with gannett read senator ryan hasn't voted for cloture, isn't convinced the bill would in fact be the deficit neutral and reduce the deficit and he says he wants to make sure that will happen before he votes. sounds like you're saying he should be sure right now there isn't anything that needs to be added to this bill that would make sure that it happens. >> will again i think the bill as it stands meets those four conditions, and again as i said, has -- embodies the most cost containment and delivery system reforms of any bill that's been considered on the floor of the senate. that having been said, as i also noted, more can be done, and as you know there's a group of moderate senators considering an amendment that would and bought

some of the changes in especially in the delivery system reform component of those four pillars. >> second question ought in the back. yes. >> thank you 13 the sorry for taking so long to get the microphone paul starr argue also that a strong trigger as opposed to a public option in its current incarnation would be the best total premiums down in the private insurance market. and i'm wondering if you concur with that weather at this point the public option has been watered down to the extent that may be replacing it with a strong trigger would be preferable. >> i think what i will do, given the sensitivity of on going senate discussions is just note that there are a lot of those discussions going on, and lots of discussions about opt out of tin, triggers, and leave it at

that. given that the bill is on the floor and there are many sensitive discussions on going. >> all right. let's stay in the back and go to the next hand over. it looks like that is julie rovner. >> rovner from npr we think our first guest was pete starr. the congressional budget office and the joint tax put out a paper on monday that suggested that premiums would not as the insurance industry suggested sky rocket under the senate bill but it also suggested for most people there wouldn't be very much of an impact on premiums now the president when he was running promised $2,500 a year decrease in premiums how is this going to sell, and do you agree or disagree with the cbo joint tax assessment of what premiums would do and this i guess would be in 2016 under this bill. >> there's a few things to know. first, as you know having read the document, for those that go

into the exchange anderson supplies, for those are the majority of the folks who will go into the exchange, there are dramatic reductions in excess of 50%. i would also note that remember the analysis was done for 2016. therefore it does not reflect more in some sense should it because these things take time -- does not reflect all of the changes we've been discussing with regard to delivery system reforms and those pillars and what have you. the whole pillar of the case is the current system is unsustainable, and that you are putting in place and infrastructure so that we can make better decisions in the future, and help to move toward quality and low cost. and i think that is exactly what the legislation is doing. >> all right. let's come april 4 -- a rome forward.

paul cruickshank. using tebeau pursuing as far as taxing health insurance. does that basically right of the house approach? >> i don't know that i explicitly endorse anything to get i think what i said is that these economists have put out the four keepers, and getting the administration supports the thrust of those key pillars, is we are in favor of a fiscally responsible health reform, and again, i think we have got a vision here of what that means. >> move over to martin kondracke. >> i don't expect you to tell what is going to be your budget but you are going to tackle the long-term deficit. now everybody has said that the key to tackling the long-term deficit is to bring entitlements

under control, yet, the entitlement reforms, these of the medicare, are in this bill to pay for the health care system, so are you going to include more medicare reductions in the budget in order to bring things under control or is medicare not going to be part of the long-term deficit six? second question, the president made a stirring appeal last night for bipartisanship. the question is can you or can you tell me what's wrong with the two main republican ideas? juan, medical malpractice reform that really sticks, and secondly, the ability of people to buy insurance policies across state lines. >> let me deal with that second one first. and actually you know what, rather than going into a critique let me just point something out on that and then turn to your other question. the folks who say the bills are not doing enough for the savings are not adequate or what have

you typically point to cbo scoring and say the savings are not sufficient or cbo is not able to nor should it project forward five or six decades and say this is what is going to transform the health care system. and then when pressed what specifically would you do to meet that situation better. the answers are the two things that you mentioned: being able to purchase insurance across state lines and medical malpractice. so a few old people to the, you know, to the consistency standard and say what does cbo say about those things the answer is cbo says both of those things would have very, very modest effect on costs and quality. so just for the sake of sort of intellectual consistency, if you are going to point to cbo and say the bills don't do enough even though cbo suggested that they are deficit reducing, and

then put up those two proposals as the key missing ingredients you should be willing to live by the cbo analysis of those provisions, and again, they are not overwhelming. i would also point out that as you know, the house has a national exchange, whereas the senate has a state based exchange system. in a world in which you have national exchange as under the house built the ability to purchase insurance across state lines but becomes effectively muted. so under the house bill it's not even really particularly will find. with regard to the first question obviously we will have more to say about what will be in the budget when we put out a budget. but i would want -- i want to highlight that with regard to moving toward a continuous improvement system, so getting in place and innovation center, for comparative effectiveness research, in medicare commission it strikes me that it would not

be practical -- i'm not licensed to practice politics and you know more about that than i do but it strikes me that it would not be practical to get those kinds of provisions and to just an entitlement reform bill. and it will be a remarkable accomplishment if we succeed in passing this legislation, again because it puts in place a structure that allows future and heileman decisions to be oriented towards quality and efficiency in a way that doesn't really exist today. so we will have a lot more to say in february. i will note that fiscally responsible health reform is necessary but not sufficient to address our medium-term deficit and long-term deficit problem and there is more that will be necessary and we will be talking more about that in february. >> what's the question in the front from cheryl.

>> cheryl from the new york times. i would like to ask a average joe question. you talked about fleeing the foundation for a system that would be more efficient and pay for quality, not quantity and i think a lot of americans would like to know over what time frame do you envision this system emerging? when will we be able to see in this country that we have a health care system that is efficient that works properly? >> well, i think there is not a sort of demarcation point where we declare mission accomplished. it is a gradual process that we will be moving forward, and that is -- >> [inaudible] >> it will be years to decades, but just continuous improvement, and that is the point. there are some key missing pieces that do not exist today.

your doctor machen to many cases today does not have any basis, doesn't have the evidence to know whether this approach for that approach is better. and we need to be reducing the number of situations in which that's the case. >> [inaudible] >> no, the point is -- >> [inaudible] -- that's already more than five years away, but, you know, sometime beginning five years from now? >> no, i think it is going to begin before that. remember, we have the health of i.t. funding and comparative effectiveness research that's in the act that's going to be occurring much sooner than 2015. but this is -- this is not -- i think this is the key thing, this is not one of these -- improving the quality of health care it's more like a lifelong nutrition or dye it, not studying for an exam. you don't just study for the exam and you are done with it.

it requires continuous effort, and what you are doing in this legislation is putting in place a system that will make it easier to do and more auspicious approach than what we have now. but just like with a lifelong effort it's not like you are done at any point. it will require continuous effort, and therefore it's not -- the reason i'm not giving a specific answer is just something that you have to keep working at. >> spoken like a true middle-age person. >> there you go. [laughter] >> in the rear, please. >> rich edson with fox news. you talked a lot about the excise tax. it's been weakened a bit in the senate version from the finance committee had originally come up with. there is some talks about perhaps a different index, maybe to weaken it further. are you comfortable with the levels at which that tax sits

now, or can there be further modifications to it, or should it be made stronger? >> i think the key -- most of the discussion about changes between -- welcome because it was the main thing change between the senate finance bill and the floor -- involved the starting threshold. and what is key from the cost containment perspective is the rate at which that threshold is increasing over time. and that was not changed to read and the reason that's key is when you're doing with regard to how rapidly that threshold is rising is that you're reading incentive for plans for employers to design their plans in such a way that under that threshold since the threshold is rising more rapidly than health care cost york reading incentive for health care cost without reform you are creating incentives to growth rate in private health cost. cbo, for example, suggested that with regard to the people whose

plans would be in that zone you could get a nine to 12% reduction in premiums by 2016. the result of that is that you shift compensation from health benefits into take-home pay. and that's why most of the revenue that is coming from this provision actually comes because plans -- companies are able to make their plants more efficient, as a result of take-home pay goes up and as a result there are some associated revenue with that. >> [inaudible] >> what i said was from a cost containment perspective the index, the rate at which it is increasing overtime is more important than where you start. >> just to follow-up on that quickly, peter, why isn't it possible that the risk will simply be that individuals and up bearing more of the health care cost an employer simply increase co-pays or cost sharing so that in effect the health

expenditures are maintained it's just that we end up bearing more of them as individuals? >> well i think there's a couple of responses. one is most of the evidence suggests, not most, basically all of the evidence suggests that with a very generous health insurance plan relative to a more, you know, efficient, moderate -- very high-cost plan as opposed to a moderate cost plant utilization rates are much higher under that higher cost plan. so it's not just that you are sloshing money. it's easy to slosh money around and shift money from an employer to an employee. what the evidence suggests what happened though is that the aggregate amount expended on health care declines, and that means that the increase in take-home pay in your cash wages is more than sufficient to compensate for any additional health care costs shifting, and you wind up with more available

cash. >> question back in the rear, please. >> anna edney with, chris daly. there are some members still uncomfortable with the bill or what to make changes to what the administration to stakes ackley where they stand on those differences, a public auction, an employer mandate. do you expect there will come a time and when the administration will do that if not, why not? >> well, look, the at fenestration lead out our views on a whole variety of questions. there's been lots of people who have raised questions about i suppose the legislative strategy. but i would point out again we are further -- it is worth pausing we are further along in getting a comprehensive health reform than we have ever been before. and i would also note, i probably should have said this from a cost containment perspective, if a year ago, november or december of last

year, someone told you that a bill would be actively debate on the floor of the united states senate, the expanded coverage by more than 130 million, reduce the deficit had a middelkerke commission in and excise tax on high-cost plans contained in it i think most of you would have been to say that you have been skeptical would have been an understatement. so, people can always complain or question, but judging by results we are further along, and under the leadership of the folks running the legislative strategy piece of this further along than has ever been the case before. >> move over to the other side of the reimputed let's take a question in the front, please. >> joyce frieden from internal medicine is. the journal puts a lot of perspective on getting the most cost-effective treatment for things and i'm wondering if the

uproar over the mammogram and pap smear guidelines has given you any concern about whether people will be able to put into effect the changes that will mean fewer treatment or procedures? >> i think the goal of the comparative effectiveness or patient center researchers to make sure that your doctor has as much -- more information now, i mean in the future than now on what will work. and the big problem that i see -- there are a lot of cases where the evidence is ambiguous and folks candidate, and that would include the recent discussion in that category. the more important problem from my perspective there's lots of areas, and too much health care spending where we simply have no evidence whatsoever about whether what is being done as beneficial especially relative to an alternative, and that's where we should be focusing attention, building up -- let me put it this way; if the problem

were that we had evidence on all of the things that were being done and there were -- there was that category of ambiguity across la whole area of health care spending that would be a high class problem at this point. we're it's not clear what the benefits or and if there is no evidence either pro or con that has been developed and that's what we need to be doing. >> we will stay on that side of the room for a moment and take a question in the next row behind. >> lauren montgomery with washington post. they also rejected the medicare commission. how critical is it that the final bill that the house leadership be persuaded to adopt in the medicare commission? >> well i don't know that i would use the word reject it as opposed to not included in their

bill. [laughter] look, i don't want to get into, you know, let -- there's a bill on the floor of the senate, the next stage after the senate passes the bill as you know will be between the house and senate. let's let this play out. >> to bill medicare commission question, there's a number of proponents of the commission who think the version even in the senate legislation has been greatly defanged. if you look at the language it is not clear what the commission would be able to do or recommend and some of the things it's been restricted from taking on like hospital payments would suggest it isn't going to have very much leverage. why would we consider that a really firm pillar of the reform at this point, given how much it has allegedly been defanged? >> i would say two things. first for those who argue that none of these things matter, they're sure is a lot of effort going in to try to alter or change the provisions. so there is a little tension between sagging none of this is for real and then we are going to put a lot of effort into

weakening or changing, what have you. i think the key thing at this point is the medicare commission exists, and as i said i think there are things as we move forward that will need to be tweaked and modified, and i know that there is significant discussion on going about with the medicare commission, the provisions of the medicare commission could be modified as the process moves forward. >> okay. we will stay and get on this side of the room and picked up a couple more questions and come back over here. right there. >> nor with the l.a. times. >> there have been discussions perhaps unrealistic that controlling health care spending, the key to that would be talking to use money within the health care system to offset the iain for coverage expansion. but it seems in fact that the legislation has and going in the opposite direction in some sense that the addition of the medicare payroll tax for high

income earners, even the cadillac tax is dependent in some sense of the income tax that would to offset the cost. how concerned are you that given the dynamic in essence we are just pumping more money from outside of the health care system into the health care system going forward and that will only exacerbate the problems of excessive spending? >> will actually, i would say, again, since the one that is being debated right now wish to take the senate bill the vast majority of what is happening is that you are taking resources that are already committed to health. redirecting them to words, you know, in various ways, so the vast bulk of the savings that are used to finance the coverage, more than finance because we have a net deficit reduction more than finance the coverage expansion comes from within the health care system will not only reducing some of the inefficiencies and other things in medicare and medicaid,

but i would include excise tax as coming from a commitment of the federal government that basically it reflects tax expenditure that is currently devoted to health care and it is curtailing the tax expenditure. >> we will come back over here and take a question right here in the center. >> doug trapp with american medical news. you spoke a lot in the past about the dartmouth callis conclusions and how there was potentially 30% health spending was not effective for was inefficient. i am wondering since then the past two months there has been a scaling back by the dartmouth folks, and i'm wondering do you still believe that number is workable estimate or is there some other smaller figure you think is more realistic? >> gerstein not aware that dartmouth either italy fisher or dr. weinberg or others have scaled back their number at all.

there was, just worth pointing out, there was a mid peck report that came out yesterday that examined the variation in spending variation in utilization patterns, that is once you adjust for different wage rates and health conditions of the population, and what it definitively suggested is that although once you control the differences in the wage rates and health conditions across the regions and across the parts of the united states, the variation is less, so in other words part of the explanation is that external factors vary. there is very substantial variation that persisted, and that is consistent with evidence that when i was the director of the congressional budget office we examined, suggesting this huge variation in spending across the united states for reasons that are not correlated with outcomes, and that the various sex planetary -- the

variables you can use to try to explain might reduce the variation by say one-third or one-half leaving a huge amount of the variation that is not explainable and that is not correlated with outcomes. and in fact if anything the higher spending regions seem to -- this is worth pausing. we have very significant variation across regions of the united states, across hospitals within a region and even across doctors within a hospital. and the kicker is never you drill down into any of those levels across regions the variations across the walls, variations across the doctors, and try to examine whether for a given type of patient the folks who are doing more spending get better outcomes the answer is almost universally no. there are a very limited number of exceptions to the general conclusion, and in general if anything it goes the other way, which is -- >> [inaudible] >> my understanding is that, and

again i would refer you to the dartmouth folks. i also point out it's not just of the dartmouth folks who come up with numbers in that range. but also the mckenzie study of the cross-country comparisons, and frankly the institute of medicine workshop that has examined the potential for efficiency improvements in health care -- they all are centered around figures in that range. >> i think there may be a conflation of numbers here, too. the 30% refers to the estimates of the medicine that is of no value. not the variation. the variation is not necessarily 30% -- it is maybe 30% in some areas with respect to medicare but it's going to be different if you take into account other data. so i think it is two different sets of numbers. question right here. >> susan heavey with reuters. the economy is struggling and health care sector we points out there is one area growth is a good thing and there is a number of jobs, there is innovation.

so how do you -- how do you tackle that and reduce health care spending and the cost curve and unnecessary care? how do you factor that against this industry where jobs and the economy is still a huge concern for people? >> well, don't forget i think what we need to do is the sector needs to be experiencing the same sorts of productivity improvements commented in other sectors so that you are orienting again toward out comes rather than just giving more to it and no other sector do you have this -- well, very few other sectors do you have such strong incentives just for volume. and that is the right incentive to be giving any market. we want to be providing incentive for quality, not quantity. and so i don't think this really speaks to the question of the

sector's financial health or in employment levels but rather with those people are doing. we need to be getting more from the dollars that we are investing in health care. >> take a question right here from chuck babington. >> now that there is a bill the senate floor and wondering what the path is to get final passage. the you know very well what certain senators have said, lieberman, landrieu, lincoln, ben nelson -- if you take them out there were several of them are not going to vote for a bill with a public option yet many democrats in both houses are adamant about the public option. how problematic is it and what passed to you see? >> i think i'm going to let senator reid -- my job is hard enough, i'm going to let senator reid to his. he is, as you know, managing -- managing the movement in the senate and he is confident that he is going to get where he needs to be and i am going to

let him manage that process. >> [inaudible] -- can you give me any sense of what -- >> no. [laughter] >> good try though, chuck. john? >> john reichard. a key piece of the legislation as medicare cuts to hospitals, and rick pollack of the american hospital association said earlier this week the coverage levels are not high enough yet to merit of the cuts of the magnitude that have been proposed. he's talking about 97% standard of coverage. my question is whether, you know, is that feasible from your point of view financially and if so how does that get paid for? >> well, look, the legislation does include a very significant expansion of coverage. it's not surprising that various

provider groups would prefer to have more people covered and less cost containment. i mean that is sent -- isn't chaulky. but if you look at the proposals put forth by medpac or cbo it is a significant expansion of coverage without creating significant problems with regard to access, either with regard to hospitals or doctors. so i think i will leave it at that. it's not surprising that providers will always want less constraint on their reimbursement rates and more people in the business flow. >> [inaudible] >> okay. let's take one more question over here and then we will come back and pick up the final one and close this up. >> christina bellantoni but talking points memo. i'm curious about former senator tom daschle and former senator

kenneth salazar now secretary of interior and why the at ministration sending them to the hill if you have just -- obviously you can't talk about what they're seeing in these private meetings but why are they doing these negotiations right now? >> i think, look, getting a comprehensive health reform bill donner is challenging. it's a very worthwhile we are doing the things that senator reed believes will be helpful in his effort to get the bill passed. >> all right. let's take a final question. >> janet from "the wall street journal" to regard their cost containment measures not in the legislation that you think should be and if so, what are they? >> i think as i said, there are always things that could be strengthened and as the process moves forward, perhaps, you know, we will be paying attention to further tweaking. but i want to again emphasize to have a group of very impressive

and bipartisan economists know about health care who laid out with a fiscally responsible health reform bill is and that's what i am focused on trying and the administration is focused on trying to accomplish and we are hitting in the senate bill checking the box on all four of those. within them there are things that can be changed some of which can be strengthened and some of which come up but it is worth began noting that in each a riga all four of those provisions are there and that provides an opportunity as the process moves forward to tweak or strengthen or modify as need be to get to the best possible bill but even as it stands this is more than has ever been done to it >> peter, finally, the m and a wendi stands for management and as you said implementation is a huge issue going forward. there are fewer employees now at

cms than there were 20 years ago. what is the capacity of the government now to implement much on the agenda? there are innumerable references in the legislation to the secretary. why would one expect we have the capacity to put in place this enormous amount of change just within the u.s. federal government alone? >> secretary sebelius has in fact, she and i talked about this yesterday, i think there is significant focus on making sure that resources are provided to execute while on this will be a thing but let's get the legislation donner and then we will need to turn to making sure we are executing and implementing well. one of the benefits of having a lead time where the exchange operation does not begin for several years for the exit was that it gives you time to get the details right and it will be hard work you do have the time to do it. >> we hope you'll come back and

talk to us about the implementation phase going forward. peter, thank you very much for joining us today. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations]

low dose radiation for mammograms or chest x rays may put some young women at increased risk of developing breast cancer a new study suggests now is one of the topics of the health subcommittee hearing. congressman franks was pallone of new jersey is the chairman. >> the meeting of the subcommittee is called to order and i will first recognize myself. the subcommittee is meeting today to review the new breast cancer screening recommendations issued by the u.s. preventive services task force just a few weeks ago. by now i'm sure everyone in this room is familiar with the new guidelines or at least with the controversy surrounding them. from what i've heard from my constituents, friends, family members and academic institutions in my district there are a lot of questions,

frustration and confusion around these new recommendations. the controversy that was ignited by the report may be eclipsing what the report actually says. and this is the reason why i am holding this hearing today. it's time for all of our questions to be answered. we want a clear understanding of what the report did and didn't say and what others have to say about the report. we also want to understand the process used by the task force should they operate for example with more transparency. do they get sufficient input from secret war groups? to be considered different opinions? and i have invited u.s. preventive service task force to speak directly about the work. it's my hope that we will all walk out of this from later today with a better understanding of how these recommendations came about, how they should be viewed and what exactly they mean. we want to get these answers, we want to know as much as we can because women and their doctors to deserve to know what is best. i also want to hear from

organizations, efficacy groups and medical experts who don't want the task force report to stand alone if there are different opinions. i know that some of the frustration is due to the fact this recommendation was seemingly made with little input from these groups. that may be a problem of process as well as a problem with the substance of the report and they will have a platform and a voice today. the united states is at the forefront of medical research and innovation. investment in science is led to the development of early detection methods for certain cancers. it led to treatment and cure for disease once considered a death sentence to read and its import all of this new medical information is used to in power physicians and their patients when making medical decisions. this information should be used to help patients and their doctors. it should not be used and i stress it should not be used as an excuse to deny eckert immediate care. scientific studies enable patients and their physicians to make more informed decisions about what is best for them in any given situation.

these studies should be one of many tools. patients and their doctors should have access to as much information as is available. this should help inform conversations but the decisions about mammography for women in their 40's should remain with women and their doctors. there is a lot of disagreement in the medical community about when exactly the began using mammography screening for breast cancer pasties have shown mammograms save lives while at the same time others highlighted the risks associated with the test. for example an article published in "the new york times" just yesterday cites a new study that indicated that the risk associated with the yearly mammograms can actually put high risk women at an even greater risk to develop breast cancer in their lifetime. at the same time the study cautioned more research is needed to make a more conclusive recommendation. it appears to need to take away message from this is more research is needed and there is already quite a bit of disagreement within the community as what is best, as to what is best for the patient.

but remember the goal is to provide the best way preventing, detecting and treating breast cancer all of the study reports and recommendations should be used with that goal in mind, and i also believe that we do not want this study or any other study to be used as an excuse by insurance companies or others to be like mammograms or treatment that would help women. and again that decision should be between the women and their doctors, not the insurance companies. essentially we want stakeholders today and the task force and groups to be heard. we want people to understand whatever recommendations are made and what the implications are from these recommendations. i want to thank the witness is here today for coming on relatively short notice. and at this time, i would recognize our ranking member for our temporary ranking member i guess, the gentleman from new jersey, mr. blood. >> thank you. mr. diehl will be here at some point during the hearing.

i'm glad substitute for him in this chair i certainly thank you for holding this hearing. on the recent recommendations on breast cancer screening i think there will be large agreement from the committee and concern about those recommendations. these new guidelines for these new proposed guidelines have caused a great deal of confusion for women and their families. the u.s. service task force no longer recommends routine mammograms for women between the ages of 40 to 49. yet this group accounts for about one out of six instances of breast cancer to it i believe it is a huge mistake to send a message to women and their families and health care providers that an early alert system has not been beneficial or may not be beneficial. and as a cancer survivor myself on i am very interested in hearing from members of the task force on by these recommendations were formalized,

how they were finalized and then communicated to the public because i know how important screening was for me on two different cancers on two different occasions as part of my annual physical. as we all know, health care reform has been a hot topic for this congress and a time when we have been talking about encouraging more prevention in the health care arena these recommendations run counter to almost every other discussion that we are having. i am also concerned how these recommendations could be interpreted should the house passed health care bill become law rule. i find it unlikely or at least questionable that the government-run health benefits advisor recommitting would propose including services in the central benefits package that another government appointed board has recommended are not necessary. mr. chairman i think this is an important hearing. i congratulate you for holding it. i look forward to working with

you and ranking member mr. deal from georgia on the subcommittee as wheat board to figure out how and why these confusing recommendations were made. -- before, mr. blood. next is the chairman mr. waxman, the gentleman from california. >> thank you, jeneane pallone for holding this important hearing. today we are going to talk about an issue about which people have strong views. which women should be routinely screened for breast cancer and when. it's a question that resonates with every person in this room. we all know someone, family member, friend, who has received breast cancer diagnosis. in some instances it's me younger woman in the prime of her life indeed just a few weeks ago the subcommittee heard powerful testimony from a member of our own congressional family representative wasserman schultz about her diagnosis and treatment for breast cancer at

age 40. the guide lines for breast cancer screening that were recently issued by valueless preventive services task force have placed this issue front and center again. i emphasize the word again because this is not the first time recommendations about the use of mammography and breast self exams have been revisited by the task force or nih or any member of cancer related research or advocacy groups. just as we have seen with prostate cancer screening immunization schedules and even last week cervical cancer screening as well as numerous other services new information or interpretations of old information often result in a change in what the experts tell us works s all or works most effectively at all. this is how it is supposed to be. as a science of medicine

involves so too should the recommendations on the best use of that science. i believe that is what the u.s. preventive services task force set out to do in making a review of its 2002 mammography guidelines to take a fresh look at what has been learned over the past several years and based upon the body of work to provide its best professional judgment on but to doctors and their patients should consider when they are making decisions about breast cancer screenings. while that may be contentious i have no doubt it was driven by science and by the interpretation of science and not by cost or insurance coverage or the ongoing health care reform debate. i'm also confident that these recommendations are just that. recommendations and the task force would not expect them to be used to take place of the

considered opinion of a physician and patient. as we will hear shortly there is a deep divide up the guidelines among other experts that i believe work, together with the task force share the primary goal of ensuring the best possible care for women. we want to learn more about those differing views today and understand better exactly what the task force has proposed and why. but in the end what must prevail is a set of recommendations that is evidence based, backed by science and supported by experts in the field. american women and their doctors deserve and are entitled to nothing less to inform their decisions not to make them but simply to inform them. i hope that will be the focus today. i look forward to hearing from all of our witnesses and thank them in advance for their testimony. thank you, mr. chairman.

>> thank you, chairman waxman. next is the gentleman from illinois, mr. shimkus. >> thank you. i hate to disappoint mr. waxman that this will not be the sole focus today because this is the canary in the coal mine. this is what we get when we have government intervention starting to dictate health care policy decisions and this will not be taken outside the context of h.r. 3962. which will then set up again from a system and will intervention care. when we have governments setting policy instead of a doctor and patient relationship to get this. so don't be surprised if we do not focus on how this is just one small example how health care will be delivered in this country. pretty soon 2013, and definitely to or 15 years we will be and to

point out in h.r. 3962 the ratings of eight and be in the essentials benefits package and the highest rating of see women would not receive access to a regular mammograms until the age of 50. one estimate fines rationing care like this would result in 50,000 preventable deaths from women who go undiagnosed. h.r. 3962 does give the secretary of the ability to add benefits, but only after getting a proven to do so from the new bureaucracy that is created called the health benefits advisory council. well the new health benefits advisory committee take into account cost when making decisions? will the committee and make recommendations another government board like the task force has said shouldn't be covered? when mammograms and other services are not covered by government where will people turn?

in canada we know those people can turn to the u.s. market. in the u.k. they are allowed to do -- they are allowed to purchase their own private plan. thus creating the two-tiered system. under h.r. 3962 we create the same system for the rich, one for the rich and one for the poor. the secretary cannot prove additional benefits to be covered or enhanced in a premium plans to be offered in exchange. these plans will cost money and in 2013, 2014 anyone receiving subsidies to help them afford insurance can only purchase the basic plan. how will these people receive coverage? so here is proof. the government will have the ability to come between you and your doctor and that we will not need a single-payer to get there. the government from public option will allow them the same ability to ration care and i yield back my time. >> the gentleman from california

>> thank you, mr. chairman, for holding this very important hearing today. i want to welcome the witnesses, the members of the task force, the national breast cancer coalition, the american cancer society and the susan g. komen foundation here today as well, and to thank you all of for your work. i will put full statement in the record but there's a couple of points i would like to make at this moment, and that is number one, i think that if we wandered away from science, from evidence based science in our country it will be in march to folly. sometimes we debate and should and question the scientists and

how the air right at the conclusion that they have come to. but science is something that has been honored by the american people for a very, very long time. we have come through a period of time where science was not honored by the congress. it was political science that drove it and scientists within the government for the muzzled and we paid a price. certainly the task force and coming out with their information, i wish there were a better communications plan. people were not prepared a will to sudden to be hearing what the task force came out with. but now is the sober and prudent time to examine with the task force has come out with and why and where that may take us. now on the issue of national health insurance of course our

republican friends are going to try to drag this into that. but i remember too many times where they were too slow to take up the call to reform, reform, to bring services to women especially poor women in the fight against breast cancer. so, today is a most important hearing and we need to remain i think devoted and dedicated to solid science and the country and paid heed to that, and i think that drives to the core of what we are here today for and god help us if we don't. this is not about anybody's political science as much as members are tempted to dragged into it, and i might say that insurance companies, who they

want to ensure and what they will cover. and women and their complicated bodies have been left out of so many of those decisions and not covered by them. and that's why we have engaged in a new debate and hopefully we will be successful with our efforts to reform all of that. mr. chairman, thank you for having the scientists, the experts here today for us to query, to understand better and their recommendations and that with that we will be far more confident about the discussion and the the they've brought forward. thank you. >> a thank the gentleman. the gentleman from texas, mr. burgess. >> thank you, mr. chairman. i agree with the gentlelady's previous statement the fight against cancer knows no ideological or partisan lines, and certainly doctors will be testifying before us today would

agree that it is a disease, cancer is a disease all americans fear and one that is all too often very close to home. we have learned in this committee cancer is a complex disease, still has no cure but efforts geared toward prevention, really detection and treatment have made significant gains. we start their because as we embark upon this hearing we must remember not to embrace policies that would undo the success we enjoyed. i agree we should not meet this partisan but the 2,000 page to rely in the room is the bill this house passed two weeks ago and if things were just to stay as they are now the task force recommendations would be recommendations doctors agree to accept or reject them. but what we have written the legislative language me take some of that freedom away from doctors and take some of that freedom away from patients as well. cancer strikes roughly one-third of all women in the united states and