breast cancer deaths. as a medical oncologist who actually treat breast cancer patients i have treated hundreds of breast cancer patients in my career. i have observed first-hand the heartbreak this disease has on women and their families. over the years i have also witnessed the advances we have made in early detection and treatment. advances that have led to for fewer women from suffering and ultimately dying from this dreaded disease. i can't help but note that in our current system our society for halve it's a large number of women, 30 to 40% of those who should be getting mammograms from getting mammograms. i also left a note that my own research published before this committee before has shown that uninsured women at the same stage have poor survival compared to insured women at the same stage. that is to say even when early detected insurance is a prague

nastic factor in breast cancer. mr. chairman as you know the society in recent weeks has publicly disagreed with the recommendation of the u.s. services task force with respect to mammography. let me say right now i have tremendous respect for the task force as an academic position i look forward to virtually everything the task force has published over the last 20 years regarding cancer.

people become more and more perplexed about the democratic plan for health care, and they like it less and less. americans thought reform meant lowering costs. this bill actually raises costs.

americans thought reform meant helping the economy. this bill actually makes it worse. americans thought reform meant strengthening medicare. this bill raids it to create a new government program that will have the same problems that medicare does. americans wanted reform. what they're getting is the opposite. more spending, more debt, more burdens on families and businesses already struggling just to get by. one of the biggest sources of money to pay for this experiment is medicare. this bill cuts medicare advantage by $120 billion. it cuts hospitals by $135 billion. it cuts home health care by $42 billion. it cuts nursing homes by $15 billion.

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

vital program in order to create another one for an entirely new group of americans. so a vote against the mccain amendment is a vote to take money out of medicare to create a program for an entirely different set of americans. a vote against the mccain amendment is a vote against our seniors and it's a vote against real health care reform. mr. president, i yield the floor. mr. dodd: how much time remains? the presiding officer: 13 1/2 minutes. mr. dodd: let me yield myself 5 minutes if i may, mr. president. i just want to come back if i can. do you have those charts with you? i want to put up these charts. again, i say this respectfully because i genuinely believe people across the spectrum here would like to see some reform of

the health care system. the question is whether or not the proposal that has been laid before us here by the finance committee and the "help" committee achieves reform and whether or not the ideas we bring to the table are actually going to achieve lower costs, greater access, improve the quality of health care. we believe very firmly and strongly that it does, and outside observers of this process who have no political agenda whatsoever but really make a determination as to whether or not the goals that we have sought in this legislation achieve the desired results are there or not. it is the conclusion of the major organizations that make these determinations that in fact we have done exactly what we set out to do. but i want to point out because i think it's important, what i wh*e i hear the arguments from our friends on the other side about their deep concerns about medicare, it's very, very important that they understand that over the last number of years we've seen quite the opposite reaction when it comes to the medicare program in our

nation. going back, if you will, to 1995, when our friends took over the control of this body and the other body and began a process. the then-speaker of the house newt gingrich announce the to the world that he was prepared to let medicare -- and i quote him -- wither on the vine. that is not 1965 when the program was adopted. that is merely 15 years ago, 14 years ago when the other party became the dominant party in congress. one of the first statements from the leader of that party was to let that program wither on the vine. again, that's one person, the speaker, the leader of the revolution that produced the votes electorally in 1994. i think it is a backdrop when we hear the debate about medicare, it is important to have some history on where the parties have been on this issue generally speaking. in 1995 we begin with that as a

backdrop. in 1997, two years later, it happened again. in 1997, here were the proposals. in 1997 medicare's funding as proposed in the republican balanced budget act of that year were twice of what we're talking about in the savings of this bill. a 12.4% reduction in medicare benefits in 1997. and of course in the last budget submitted by president bush last year -- and i think, again, it's reflective of where things were at. this is a year ago, not 14 years ago or not 1997. in 2009, the bush administration in submission of its budget proposed a $481 billion reduction in medicare benefits. that was not in the context of a health care reform bill. that was just in the context of a budget proposal. here we're talking about savings by reducing costs in hospitals and other providers as a way of strengthening medicare, providing more benefits to the beneficiaries themselves and

things like prescription drugs as well as in screenings and early prevention efforts which are included in our bill which have been identified, of course, by aarp and the commission to preserve and protect social security and medicare and they have analyzed our proposals and suggested we do that. our bill saves $380 billion in order to strengthen the medicare proposal. it improves the quality of health care for seniors as part of our comprehensive reform. stph-fbgt, senator coburn -- in fact, senator coburn's patient choice act proposals more cuts in medicare advantage than our bill does. i find it somewhat intriguing for those who are arguing for the coburn proposal as an alternative and yet simultaneously suggest we ought not to do anything to medicare advantage have not read the coburn bill. because he cuts $40 billion more out of medicare advantage than

what we do in our legislation as proposed. in conclusion from the national committee to preserve social security and medicare, again, not a partisan organization -- their sole mission is to see to it that social security and medicare will be there for the people who it is intended to support. in a letter sent toefry united states senator yesterday to the commission, let me quote exactly from them, "not a single penny of the savings in the senate bill -- the bill now before us, mr. president -- will come out of the pockets of beneficiaries in the traditional medicare program. the medicare savings included in the house bill, the patient protection affordable care act, will positively impact millions of medicare beneficiaries by slowing the rate of increase in out-of-pocket costs, improving benefits, and it will extend the solvency of the medicare trust fund by five years. to us, this is a win-win for seniors and the medicare program." end of quote. we could hear all the partisan debate back and forth as to what

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

those guaranteed benefits senator baucus addressed in his remarks. that is why this is a good bill and deserving of our support. i urge our colleagues to reject the mccain amendment. mr. president, i yield the floor. the presiding officer: the senator from montana. mr. baucus: mr. president, the republican leader just a few moments ago says that this bill raises costs. with all due respect to my good friend from kentucky, that statement is false. just this week the nonpartisan congressional budget office, the organization that analyzes legislation, both sides, both bodies depend on it -- a very professional outfit, i might add -- said that our bill would reduce premiums, not increase, but reduce premiums for 93% of americans.

and for all americans, it would make sure that better quality insurance is available. let me state that a little bit differently. the congressional budget office said that for 93% of americans, premiums would be reduced. it is true that for 7% that's not the case. those are americans whose incomes are too high to qualify for subsidies. that is, the tax credits, buying insurance in the exchange. but those 7% would get a lot better insurance, a lot higher-quality insurance than they get today because of the insurance market reforms that are in this legislation, the provisions which deny insurance companies from denying coverage based on preexisting condition, health status, the market rating provisions, no rescissions, et cetera. so for all americans, it is true

that this legislation will provide better-quality insurance comparing apples with apples. 93% reduction for all americans. the other percent for whom there is not a reduction, those people would have a lot higher quality insurance. add to the fact the quality would be much higher, it would be succeed the increase in -- it would exceed the increase in premiums. this is looking at it to the year 2016. they didn't look at it for other years. at least that is the case for 2016. reduction, not an increase. reduction. in fact, for many in the nongroup market -- those individuals who buy insurance -- they find their premiums will be reduced about 40% or 50%. about 60% of those in the nongroup market are finding

their insurance premiums will be reduced. i don't have the exact figure in front of me, but it's in the neighborhood of 40% or 50% reduction in premiums. that's due to tax credits. again, c.b.o. says that those tax credits would cover nearly two-thirds premiums. i guess that is a little conservative. it would cover two-thirds of premiums. c.b.o. says that those getting these tax credits would pay roughly 56% to 59% lower premiums than they would without our bill. and those are real savings, mr. president. that's with respect to premiums. what about out-of-pocket costs? this legislation has absolute limits on out-of-pocket costs. today insurance companies can give you -- sell you a policy. you pay certain premiums. if there is no limit on the out-of-pocket cost you have might have to pay or deductible is so high, for example, this

legislation puts an absolute limit that no policy can be sold that allows you to have out-of-pocket costs above a certain amount. i think it's $6,000 for the individual. it might be double that for a family. but there's a limit. so this bill does not, as stated by the minority leader, raise costs. in fact, the fact is it reduces costs. in addition, there are many people who say, oh, gosh, this is a $1 trillion bill. some even say it is a $2.5 trillion bill. senators on the other side of the aisle make this statement. and they say this to try to scare us. i think they kind of -- i'll be honest with you, i don't know if they really believe it but they're saying that because it is a nice, good scare tactic. i say i'm not sure they really believe it. i wonder if they believe it, because when you read the legislation, it is deficit-neutral. it does not add to the deficit.

we have a budget resolution, mr. president. under that budget resolution, the budget has to be deficit-neutral. it cannot add one thin dime. when people talk about a trillion-dollar bill, it doesn't cost anything, it reduces the deficit by $130 billion in a ten-year period. that's what the congressional budget office says, the professional nonpartisan budget office. and the second ten years the c.b.o. says our bill reduces the deficit by a quarter of a percent of g.d.p. well, that's roughly $500 billion. the second ten years, this bill reduces the deficit by a half a trillion dollars. so i don't know why the people on the other side say this is a trillion-dollar bill. there's one senator on the other side -- i am not going to say his name -- this is a $2.5

trillion bill. i mean, it is not true. just not true. it's not true because it's paid for. now, i can say that something costs something, but it will be only fair if i also say that it's paid for. i think it's fair to give both sides of the story, not just one side of the story. and i'm giving both sides of the story. it does cost $1 trillion over ten years, but it is paid for. it is more than paid for. and those that say $2.5 trillion, they start at a different date. they start at a date like 2014 up through 2020. that's i didn't think so it costs so much. well, it's paid for during those years, too. so this bill is to make -- just to make it very clear here, this bill does not raise costs. it in fact lowers costs. the congressional budget office says so. this bill does not add to our federal deficits. in fact, it reduces our federal

deficits. and i would just urge us to look at the facts closely whenever we are hear statements being made by anybody, including myself. i just urge people to kind of listen to the music as well as the words, read between the lines, see what's really going on here. what my father used to say a long time ago, basically, he said, don't believe everything you read and only half of what you hear. just take everything with a few grains of salt. i think the truth starts to emerge. mr. alexander: mr. president, i agree with the senator from montana. that's why it's for the that the that we have 22 minutes on the republican side to clear up some misconceptions. the democratic health care bill does cost $2.5 trillion over ten years when it's fully implemented. it's, if i may say so, arrogant to think that the american people couldn't figure out the difference between the first ten

years when the bill wasn't implemented in four of those years and they'd like know that it costs $2.5 trillion. mr. baucus: would the senator yield for a question? mr. alexander: if it is on your side, i'll yield. mr. baucus: is it paid for? mr. alexander: the senator is right. that's the subject i would like to talk about. it is paid for by cutting grandma's medicare. it's paid for by cutting grand grandma's medicare by $465 million over a ten-year period of time, the -- mr. baucus: that's a debate -- that's a second question i'd love to debate with you, but on the first question only, you do admit that it is paid for? mr. alexander: i -- no, i admit that it costs $2.5 trillion in the attempt to pay for it, medicare cuts and tax increases and increases to the deficit by not including the physicians reimbursement in the health care bill. mr. baucus: if i might ask one more question, i this that i we all know that the house has taken action on this position of

reimbursement. the senate will also take action on it before we adjourn. that is the so-called doc fix will be fixed, which is really a separate issue. that will be paid for. but putting that aside, the doctors' issues aside, just health care reform, i say that because we take up the doc fix virtually every year. we have don't take up health care reform every year. health care reform is an entirely separate proposition, a separate legislative endeavor here. but if the senator will just bear with me and take the doc fix -- put it off the table just for a second -- week address that later -- just for a second -- health care reform, whether you use a ten-year number or when you start in 2010 or start in 2014, wherever you start at, so it's either $1 trillion or it's $2.5 trillion, depending on where you start, without getting into how it's paid for, is it paid for, therefore it is not a

deficit? am i not correct? mr. alexander: i will concede to the senator from montana that the attempt of the democrats to pay for their $2.5 trillion bill are medicare cuts, tax increases and additions to the deficit by now including the physicians reimbursement which is the essential part of any ten-year health care plan. there may be other problems, but those are the three things that i know about that -- mr. baucus: one more question on my time? mr. alexander: fine with me. mr. baucus: is it true that apart -- is it through there are no cuts in guaranteed beneficiary payments? there are no cuts, none whatsoever in this legislation of guaranteed benefits? mr. alexander: i would say no to that, mr. president, because the director of the congressional budget office made it clear that there would be specific cuts in benefits for those who have medicare advantage, which is about one out of five seniors. mr. baucus: is it true that

those provisions are not guaranteed provisions? i'm talking about guaranteed benefits that people -- that seniors expect to get when they go to the doctor, fee-for-service, expected benefits they expect to get under ordinary medicare, not benefits that a private plan, in addition, might pay. mr. alexander: well, mr. president, in response to the senator, it is clear that there are $465 million in cuts in medicare. the president, the senator from montana, the senator from connecticut, all of us have agreed that that's half of how the bill -- or a big part of how the bill is supposedly paid for. and it's specific enough to say that $135 billion comes from hospitals, $120 billion from medicare advantage, which 11 million seniors have, nearly $15 billion from nursing homes, $40 billion from home health agencies, $8 billion from wh hospices -- that's the baucus bill that came from the finance committee, and this bill is not

that much different. and the director of the congressional budget office testified that provisions like that would result in the specific cuts to benefits for medicare advantage. he said that fully half of the benefits currently provided to seniors under medicare advantage would disappear, which the changes would reduce the extra benefits such as dental, vision, hearing coverage that would be made to beneficiaries. mr. baucus: one more question. does the senator agree that this legislation will extend the solvency of the medicare trust fund for five years and failure to pass this would mean insolvency of the medicare trust fund would not be extended for five years? mr. alexander: mr. president, i would wholeheartedly disagree with that assertion. the medicare trustees have said that between 2015 and 2017 medicare will be approaching insolvency, and they ask that we take urgent action and the

urgent action recommended by the democratic majority is that we take $465 billion out of the medicare program over ten years and spend it on a new entitlement. that's hard for me to understand how that can make medicare more solvent when you take money out of grand massachusetts medicare and spend if -- out of grandma's medicare and spend it on someone else. mr. mccain: to respond to another question, isn't it, shall we say, enron accounting when you have a proposal that you, as soon as the bill comes law, you begin to raise taxes and cut benefits and then you wait four years before any of the benefits are then extended to the beneficiaries? that -- that, on its face, is a remarkable piece of legislation. my experience, which has only been 20-some years, is that we

haven't passed legislation and said, we're going to collect taxes on it for four years and then we are going to give you whatever benefits that may adpriew this legislation. again, there has been no time in history, i would ask my colleague -- there's been no time in history where we have taken money from already a failing system to create a new entitlement program. mr. baucus: which colleague are you asking? mr. mccain: pardon me? mr. mccain: i believe the senator from te tennessee has te floor. mr. baucus: yes, he does. mr. mccain: then obviously i was addressing the person who has the floor, which i'm sure the senator from montana should understand by now. mr. alexander: well, i would say to the senator from arizona that he is exactly right. or another way to describe it, the senator from kansas said it was like writing a big check on an overdrawn bank account to buy a big, new car. i mean, that -- maybe another

way, if i could respond to the senator from arizona -- and i would ask consent that the republican senators and our time be allowed to engage in a colloquy. mr. baucus: might i ask the senator another question? with respect to the question from senator the senator from a- mr. alexander: i would like to respooned to the senator from arizona. i hope the parliamentarian is keeping track. i'm enjoying the questions. a great compliment has been paid to the senator from arizona. it is rare that a mere united states senator can have something he said begin to break through the fog and a "washington post" columnist wrote a column talking about it being all about grandma and wondering why we never mention grandpa? maybe the columnist has not seen the movie "the big fat greek

wedding," where the man said i am the head of the house and the woman said, i am the neck. the fact of the matter is we take $465 billion over ten years out of medicare. grandma and grandpa and those who are younger who are looking forward to medicare are going to be affected. and i wonder, if i may say to the senator from arizona -- and then i see the senator from oklahoma and nebraska here -- it wasn't long ago, in response to your question -- in fact it was 2005 -- when our democrat colleagues sought to -- when we sought to restrain the growth of medicare by $10 billion over five years. and this is what they said. remember, they're restraining the growth of medicare by $465 million and spending it on a new program and republicans were at the time trying to save $10 billion over five years.

"an immoral document," said senator reid. senator dodd, the senator from connecticut, "funding for medicare would be cut." senator rockefeller, "a moral disaster of monumental proportion." senator boxer in the same way compared it to katrina. senator kerry, "we're passing the costs on to our seniors." senator levin, "we're going to be hurt by this bill." irresponsible and cruel" said senator kohl. senator reid, senator hillary clinton -- that was to restrain the growth of medicare to spend it on the existing program. yet this proposal by the democrats would take $465 billion and spend it on a new program -- mr. mccain: and isn't it true, now that the senator from montana is on the floor, if he wants to enter in here, maybe he could respond to his comments 14 years ago, "we weren't trying to create a new entitlement program," which is the object of

the senator's bill. we were just trying to enact some savings in the medicare system. so what does senator baucus say -- and above all we must not use medicare as a piggy bank. what are we using $483 billion in cuts in medicare for? then the senator from montana said, "that is disgraceful. perhaps some changes lie ahead. but if they do, they should be made sore the single purpose of keeping -- they should be made for the single purpose of keeping medicare for senior citizens and people with disabilities." isn't it true that we are taking $483 billion out of a system that is failing, that the medicaid trustees say is going to go bankrupt? so the senator from montana 14 years ago at least said "seniors could easily be forced to give up their doctor as doctors begin to refuse medicare patients and hospitals, especially hospitals close." isn't that the effect of taking $483 billion in cuts in medicare?

then the senator from montana went on to say, "equivalent to blowing up the house and erecting a pup tent where it used to be." well, if that's blowing up the pup tent, i would say this is a hydrogen bomb. and finally, "staggering, staggering." and now of course under the senator from montana's bill, the leadership proposes something like $2k 50 billion in medicare -- something like $250 billion in medicare cuts. "it is staggering." we learn a lot over time, all of us do here. we learn about the issues. i hope that -- apparently the senator from montana didn't learn much because he was deeply concerned 14 years ago about very small savings in medicare. now he wants to spend $2.5 trillion, taking $483 billion out of medicare to create a new entitlement system. mr. baucus: might i rye spond to the senator in -- might i respond to the senator?

mr. mccain: the senator from tennessee has the floor. mr. alexander: i am happy to see a debate break out on the senate floor. mr. baucus: here is your chance. mr. alexander: as long as it is on democratic time. mr. baucus: it is both sides. even time. mr. alexander: no. whatever time you use should be on the democratic side. mr. baucus: correct. the basic question here is obviously how to protect medicare benefits. that's the basic question. i think most of us would agree, how do we protect medicare benefits and how do we extend the solvency of the medicare trust fund? i think that's the basic question. i think we'd all agree that excessive payments to providers would cause insolvency of the trust fund to come earlier rather than later. i think we all agree with that proposition. the next question is: what

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

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

providers -- hospitals, nursing homes, home health, hospice, pharma-- tpa*r -- pharma, 6.5%, that is the growth rate of providers. we decided to trim that a little bit. we decided to trim that down to 1.5%. it is now 5%. it is a 5% growth rate for all the industries here in an attempt to try to find the right levels of reimbursement to providers with which that trim will also help extend the solvency of the medicare trust fund. and when we talk to providers, they basically agree with those cuts. they basically agree. why do they basically agree? they basically agree because they know that with much more coverage, with many more people having health insurance, they can spread out, you know, their business. but they may lose a little on margin, they can pick up on

volume. that's exactly what their business plan is under this bill. wall street analysts say -- and i quote them -- "industries are doing great. they're doing well under this bill. they're not getting hurt." we do achieve a win-win -- i don't like that phrase win-win, but i'll use it hear. the solvency of the trust fund is being extended. and reimbursement rates to providers is fair, not getting hurt. it's fair. and that's why they want this bill, by and large. most groups tend to want this bill enacted because they know it's good for the country, it's good for seniors, and it's good for them too. mr. mccain: mr. president, could i just mention again, $70 billion with fraud, abuse and waste. and senator coburn, the doctor, can tell you, there is nowhere in this bill. the fact is maybe some of the providers have been bought off and jaw boned and had their arms

twisted and given a good deal like frma has, but the recipients haven't. the medicare recipients know you can't cut $483 billion without ultimately affecting their benefits. and that's a fact. again, conspicuous by its absence, i say to the senator from montana, totally conspicuous by its absence is any meaningful malpractice reform which has been proven in the state of texas and other states to reduce costs, to increase the supply of physicians and caregivers. and there's nothing in this bill that's meaningful about medical malpractice reform. i had a town hall meeting with doctors in my state, and every one of them stood up and said i practice defensive medicine because i fear of being sued. so if you're really serious, i say to the senator from montana, if you're really serious about this medical malpractice should be a key and integral part of it. even the c.b.o. costs it out

about $54 billion a year. when you count in all the defensive medicine, it could be as much as $200 billion over ten years. that's conspicuous by its absence. i think it brings into question the dedication of really reducing health care costs across america. mr. baucus: we've enjoyed our discussion -- mr. alexander: we've enjoyed our discussion with the distinguished chairman of the finance committee and thank him for his questions. senator coburn, who is a physician, the senator from montana has talked about doctors being overpaid. he talked about -- mr. baucus: no, no, no. with all due respect, i did not say that. mr. alexander: did i hear the words providers overpaid -- mr. baucus: i talked about hospitals and others -- mr. alexander: aren't physicians providers? mr. baucus: this legislation pays more to primary care doctors, 10% increase in medicare reimbursement for each

of the next five years. i did not use the word "doctors." mr. alexander: mr. president, i must have misunderstood because normally when we talk about providers, we talk about hospitals and physicians. we have a physician on the senate floor, the senator from oklahoma, and i wonder if he, having heard this debate, might want to comment. i might say, isn't it true that the mccain amendment which we have on the floor would send us back -- send this back to the finance committee and say if there are savings, let's spend it on medicare to actually strengthen? mr. coburn: i thank the senator. the first comment i would have is relying on what a wall street analyst says today. they have about this much credibility in this country today. look at the economic situation we find ourselves in because of what wall street analysts have said. that's the first point i would make. the second point is the majority whip yesterday said we should not cut medicare -- we should cut medicare advantage because

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

under this bill, this .5% is now going to be consumed in something out-of-side of medicare. so no longer do we have a medicare tax for the medicare trust fund. we have a medicare tax that funds the medicare trust fund plus other programs. i would say to my colleagues, i think we want a lot of the same things. how we go about it, the senator from montana recognized the fact that we're going to increase payments to primary care physicians. ask yourself the question why only one in 50 doctors last year who graduated from medical school is going into primary care? why do you think that is? could it be that the government who is setting the payment rates created a maldistribution in remuneration to primary care physicians? therefore, they choose to go where they can make 200% more

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

and in the bill it actually states that it's going to decrease their benefits. mr. mccain: very briefly, the senator from montana talked about the support that it gets. aarp? aarp makes more money from medil but other groups like 60-plus are educating seniors. a.m.a. cut a deal to get their medicare payments addressed by increasing the deficit by $250 billion. and pharma, my god, if there is ever an obscene alliance, agreement that's been made that would harm seniors because it prohibits -- it has the administration against the drug re-importation from canada and competition for -- so now we understand a little bit better why these special

interest groups, 500-some of them have visited the white house in recent months, according to white house logs. mr. coburn: the senator would probably be interested to know, the american medical association now represents less than 10% of the actively practicing physicians in this country. the physicians as a whole in this country are adamantly, adamantly opposed to this bill. and the reason they're opposed to this bill is because you are inserting the government between them and their patient. that's why they're opposed to this bill. so you have the endorsement of the a.m.a., which represents less than 10% of the practicing doctors, actively practicing doctors in this country because not only will it increase payments, but the c.p.t. code revenue's protected. that's the revenue the a.m.a. gathers from the payment system that continues to be fostered in this bill, which is their main source of revenue. mr. mccain: could i ask my colleague's indulgence for just

a moment? as you know, the majority leader seems to appear more and more frantic as he perhaps is reading the same polls that we are that more and more americans, when they figure out this legislation, are becoming more and more opposed to it. so yesterday the majority leader came out and directly addressed me saying -- quote -- "this man talks about earmarks, but his amendment is one big earmark to the insurance industry. and in addition to that, the sponsor of the amendment -- talking about me -- during his presidential campaign talked about cutting these moneys." you know, mr. president, i hate to, i say to my colleagues, take a trip back down memory lane, but at the time -- this was echoed by the d.n.c. spokesperson who echoed it throughout the flog sphere and the -- throughout the blogs sphere and the left win liberal

blogs. on october 20 it was said he accuses mccain of cutting benefits. not true. obama is making bogus claims. a tv spot, well-funded campaign, a tv spot said mccain's plan requires cuts in eligibility or both. obama said in a speech that would receive fewer services and get lower-quality care. second ad claimed that mccain's plan would bring about a 22% cut in benefits, et cetera. and the factcheck.org claims these claims are false based on a single newspaper report that says no such thing. mccain's policy director states unequivocally that no benefit cuts are envisioned. mr. president, i ask that this entire factcheck.org article be

included in the record. and i hope that the senator from nevada will stop making false claims about what -- repeating false claims that were in attack ads throughout the campaign funded by tens of millions of dollars about my positions on health care in america, which the fact checkers found to be totally false. and the nature rarity says "mccain's plan means a 22% cut in benefits. the ad displays a footnote citing an october wall street story as his authority." factcheck.org says "the journal story makes no mention of any 22% reduction or any reduction at all." so, i hope that among other things, may i describe this frustration that the senate majority leader would at least not repeat false accusations

about what i wanted to do in the presidential campaign. and it's unfortunate. i hope that maybe instead of attacking david broder, instead of attacking me, instead of attacking others who are in support of this amendment, maybe we could have a more meaningful discussion about the facts surrounding this legislation. mr. dodd: how much time remains on both sides? the presiding officer: 30 seconds remaining. mr. dodd: the minority has 30 seconds? mr. johanns: i will speak very quickly. reality does sit in quickly. we have looked at the impact on our nursing home beds in nebraska. we have about 13,000 beds dedicated to medicare. this will be a loss of $663 per bed. that affects real people. thank you, mr. president.

the presiding officer: the minority time has expired. mr. dodd: met me yield two minutes of our time to my distinguished friend and colleague from -- mr. johanns: it is very kind of you. i appreciate that. maybe it comes from my fipple -m my time as governor, maybe it comes from my time as mayor, but somehow you've got to live with the legislation that's passed, whether it is by the federal government or whether it's at the state level, whatever. you can bounce this back and forth all day, but the reality is, these are real cuts and they involve real programs that involve real people in our states. you can describe them anyway you want. you can call them excessive payments, you can do this, that, or the next thing. you can say, well, we're giving this our best shot. but the difficulty is, this is a high-risk venture. you are impacting, in my state, for example, and every senator

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

career, i am honestly questioning how much longer i can continue. to constantly be up against legislation in funding when all you want to do is make a difference in someone's life is exhausting." unquote. mr. president, this is a high-risk venture. this shouldn't be about taking our best shot. this is -- this should be about getting this legislation right. thank you. the presiding officer: the senator from connecticut. mr. dodd: mr. president, let me, if i can, again address a couple of points. first of all, i made this point yesterday but it deserves being repeated. the point that this legislation doesn't provide any benefits to anybody until 2014 is untrue. i could spend the next few minutes describing the things our bill does immediately on the enactment of this legislation. there are tax breaks immediately for small business to be able to rediewts duce the cos -- to rede

cost of health care. under our bill you're actually seeing a premium cost reduction in the small business market as well as the large group market. our legislation provides immediately closing a good part of that doughnut hole, which is an immediate benefit in the cost of prescription drugs for the editorial he will. that doesn't happen four or five years from now. it happens immediately. immediately, the idea of screenings and prevention services for americans. that is not only the humane thing to do; it is also a great cost saver. if you can identify and detect a problem early, the cost savings are monumental. we all know that. under our plans as united states senators, we get 23 different options every year to choose, from we have that benefit. i am a beneficiary of that benefit, having identified a health care problem early through screening. that was not only beneficial to

my personally because i am going to be alive for a longer period of time than otherwise, but it saved thousands of dollars in long-term medical costs if i had not identified the problem. those are simple things that are included in our bill that happen immediately. you can't be dropped by our health care carrier, as you are today. you can be dropped for no cause -- for no reason whatsoever. that is stopped immediately on the adoption of this legislation. so when i heard my good friend from arizona say there are no benefits in this bill until three or four or five years, that is just not true. and again a simple reading of the legislation would identify any number -- a long list i have here -- of benefits that happen immediately. the issue that senator baucus has raised over and over again is the issue of guaranteed benefits under medicare, guaranteed benefits. let me challenge my colleagues to identify a single guaranteed benefit under medicare that is cut by the bill before us. there is not a single benefit under the guaranteed programs that is in any way disadvantaged

or reduced as a result of this legislation. what is cut are private health care plans under the medicare advantage program. and this is the reason why we're doing this. medicare advantage overpayments cost every senior more money. a typical couple, elderly couple pays $90 more per year in part-b premiums to pay for the medicare advantage payment overpayments, even if they're not enrolled in these plans. that's $90 for every -- on average for every couple. and you get none of the benefits for it. fully, 78% of beneficiaries are forced to pay higher premiums for non-medicare extra benefits they will never see. now, again, i understand that some people would like it have these additional benefits. i understand that. these are benefits that are provided for under medicare advantage. but 78% of our elderly are paying higher premiums so that a smaller percentage of people can

get these benefits. why should 78% of the elderly in this country pay a higher premium for a smaller percentage of people under private health care plans? what senator baucus and the finance committee tried to do is to reduce those costs. those are not guaranteed medicare benefits. there's no guaranteed medicare benefit that is cut under this bill. and i defy any member of this body to find one guaranteed benefit that's reduced under this plan. i'd be happy to yield to my friend. mr. burr: i would ask the distinguished jdistinguished gem connecticut that we come up with $23 billion worth of cuts in medicare. mr. dodd: nays not allowed. you cannot cut guaranteed benefits. mr. burr: would the gentleman yield for an additional

question? is this board empowered to find $23.4 billion worth of cuts? mr. dodd: not under guaranteed benefits. that's very clear. mr. burr: if the gentleman could show me that in the language. mr. dodd: the board is prohibited, forbidden to take benefits away from seniors or increase their costs. they cannot ration care, raise taxes on part-b premiums or change medicare benefits or eligibility. couldn't be more clear. couldn't be more clear. they are absolutely prohibited from doing that. and that's the point we've been trying to make here. going after providers frankly, as we know, we have a -- hospitals will tell you themselves, in many cases, as a provider, there are cost savings there. i'm told -- and again my colleagues who know more about these details that i do -- i'm told that it's not uncommon for an elderly person to leave a hospital and on average be given four prescription drugs in order for them to take.

i'm told as well within a month or so, that average couple is not following their prescriptions very well. either they live alone or they're -- for one reason or not and they end up being reamid the. there is a -- they end up being readmitted. there is a very high readmission rate. our bill tries reduce that problem of getting readmissions to hospitals which raise costs tremendously. that's where the savings are coming from, by taking steps to try to dice the readmission rate as -- to try to reduce the readmission rate. it's trying to save money, save lives. but again i challenge -- i challenge any member to quo to p and identify any single guaranteed benefit in this bill that is cut by medicare. there are none. 78% of our elderly should not be required to pay additional premiums to take care of a handful of other people out there who i understand why they

want some of these benefits. but they ought to pay for them. i'd be happy to yield to my colleague. ) hey got involved, they'd

show us how to run a health insurance plan. they'd show us how to provide medicare benefited and save us money. some have. but by and large, if i am not mistaken, isn't the jury in -- 14% increase in cost for medicare benefits under this medicare advantage? mr. dodd: in some states it reaches 50% more. mr. durbin: when we talk about saving billions of dollars in the medicare program over the next several years, part of it is by saying to those companies who are overcharging medicare recipients, the party is over. we're going to make sure that every american who qualifies for medicare gets the basic benefits, but we will not allow these private health insurance companies to get a subsidy from the federal government at the expense of medicare and its recipients? mr. dodd: and in charge the other 78 -- and they're charging the other 78% to ge of medicare

beneficiaries to get a premium. it is neither medicare nor an advantage. quite the opposite. and you're accurate in the numbers. i want people to know, as much as we respect the colleague from illinois and his market the numbers he identifies of $14*u7b billets a costing this program -- they come from the congressional budget office. we didn't make those numbers up. that's the cost savings by modifying this program that has cost us so much, deprived the overwhelming majority of our elderly, the benefits that they get at their cost. so i appreciate very much his question. mr. baucus: is it also true that the june medpac report that medicare advantage overpayments cost taxpayers an extra $12 billion? mr. dodd: that's correct. and again that's medpac. mr. baucus: well, that's right. that's medpac. and i think the point that the senator from illinois is making, we need to be underlying two or

three or four times here and you've made it, too, senator dodd. that is, there is a huge distinction between medicare and these private insurance plans. mr. dodd: yes. i think too many of our fellow citizens hear the word "medicare advantage" and assume it is the medicare program. it is not. mr. baucus: it is not. it is a private plan. what medicare advantage is overpaying -- these insurance companies are overpaid. a lot that have goes back to the part-b -- part-d drug bill and so forth. the question is, they're overpaid. do those overpayments necessarily mean a better benefit for persons who signed up toke to for those plans? mr. dodd: no. that's according to medpac. mr. baucus: why might that be the case? i want to understand this better. mr. dodd: because insurers, not seniors, determine how these overpayments are used. too often they're used just to line their pockets, to increase their profits, and not provide

the benefits to the people who are getting it. mr. baucus: is it medicare that decides what the benefits will be for this vote? mr. dodd: no, it is not. it is the carriers that decide. mr. baucus: it is the private insurance companies? mr. dodd: yes. they're the ones who determine where the profits go. that's why it is such a misnomer to call this medicare advantage. it is anything but medicare or an advantage. mr. baucus: and it's also your nine -- the presiding officer: time has expired. mr. dodd: i would ask for two additional minutes the. the presiding officer: is there objection? mr. coburn: reserving the right to object. having two additional minutes on my side. mr. dodd: i gave someone on your side two earlier. mr. coburn: how about one? mr. dodd: make it one. but wait, i have no problem with two. the presiding officer: without objection, the request is agreed to. mr. baucus: if i could just say to my colleagues, most seniors that pay part-b premiums under fee-for-service don't get any benefit whatsoever? mr. dodd: that's correct. none. none whatsoever. in fact, all they do get is

higher premiums. mr. baucus: that's right, higher premiums. mr. dodd: 70%. almost 80% are paying more than more for a program they never get any benefit from. mr. baucus: so they pay extra and get month benefit from it. mr. dodd: so vote for the mccain amendment and you get exactly what dick durbin suggested. 70% of our elderly pay more premiums. they never get any of the benefits and the private carriers get to pocket the difference. that's a great -- that's a great vote around here. that's great health care reform. a senator: would the senator from con corporation could we characterize this as an earmark in the medicare program? mr. dodd dodd: it is -- it is to ears. in one ear, i give it two ears. mr. brown: senator dodd, we remember two years ago when the insurance carriers went to the government and said we can do something -- it later became medicare advantage. they said we can do it for 5% less than the cost of medicare. and government unfortunately made the agreement with them to sign up to do that. now they -- then what happened in the last ten years, the insurance lobbyists came here

and lobbied the bush administration and lobbied the e congress and got bigger and bigger payment. and it really is a subsidy for the insurance companies. and you say -- and senator baucus and senator durbin said it's not a form of insurance, it's a privatized form of medicare that serves the insurance companies very well, thank you, but doesn't really serve the seniors this in this country. mr. dodd dodd: and i'll sit herl day for someone to cite just one benefit under medicare cut. just one. there are no guaranteed benefits cut under medicare advantagement and nor can they be cut. our legislation bans and prohibits any cuts in guaranteed benefits. mr. durbin: mr. president, i have six unanimous consent requests for committees to meet during today's session of the senate. approved by the majority and minority leaders. and i ask unanimous consent these requests be agreed to and they be printed in the record. the presiding officer: without objection. mr. coburn: mr. president? the presiding officer: the senator from oklahoma. mr. coburn: one of the questions and one of the promises was if

you have what you -- what you have now and you like it, you can keep it. what's happening under this bill for 11 million seniors on medicare advantage is not going to happen. if they like it, they're not going to be able to keep what they have. you can't deny that. that's the truth. medicare advantage needs to be reformed. there is no question about it. i agree with it. and as the senator alluded to the patients' choice act, we actually save $160 billion into the patients choice act but we don't diminish any of the benefits. and we do that because c.m.s. failed to competitively bid it because when it was written -- and i understand who wrote it -- when it was written, we didn't make them competitively bid it. so you could get the same savings, exactly the -- actually you could get more savings and not reduce benefits in any amount if you competitively bid that product. but we've decided we're not going to do that. second point i would make with my colleagues is the vast majority of people on medicare advantage are on the lower

bottom of the economic. they can't afford an aarp supplemental bill. they can't afford to pay an practice $150 or $200 a month. and so what most of the time happens with medicare advantage is we bring people up to what everybody else in medicare gets because most people can afford -- 84% of the people in this country can afford to buy a medicare supplemental policy because medicare doesn't cover everything. so your idea to try to save money, i agree with. but cutting the benefits, i don't agree with. and you're right, senator dodd, the basic guaranteed benefits have to be supplied in medicare advantage and then the things above that, which you get with a supplemental policy of which you can afford to buy, is what these people get. and what you're taking away from the poorest of our elderly is the ability to have the same care that people who can afford

to buy a supplemental policy. that's the difference. thank you. and i -- i do appreciate my chairman

day of debate on the bill. live coverage from the national press club on c-span2. >> it never came up in the major news conferences in washington.

jerry thought that was a darn shame. also, he found that in a rare moment when health policy determines as a major issue at stake, the sperling breakfast, he couldn't get him because he was just a lousy health reporter. of course, in those days health reporter got no respect. jerry start the practice grew. many people here today were members of that group. but i thought it would be appropriate is more just to take about 20 seconds, which is about as much as jerry would already, just in a moment of silence to remember jerry 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 questions. so jerry, we miss you. and we are honored to be following in your footsteps today. i had the pleasure this morning of introducing our guest, peter orszag, who all of you will note

is the director of the office of management and budget in the obama administration. overseeing budget policy, coordinating the implementation of major policy initiatives through the government, and of course, most particularly at the moment, helping to shepherd through health care reform. from january 2000, to 2008 as you also know he served as director of the congressional budget office supervising the agency's work in the analyses of economic and budgetary issues. before that, he was a joke packman senior fellow and deputy tracked of economic studies at the brookings institution. also served as director of the hamilton project, director of the retirement security project and codirector of the tax policy center. during the clinton administration, he was the special assistant to the president for economic policy. and before that, a staff economist, and then senior adviser and senior economist at the council of economic advisers.

he is a summa cum laude graduate in economics from princeton. he owns a phd in economics from the london school of economics, which he attended as a marshall scholar. is an author of numerous books. finally coming is also an avid runner and has completed several marathons. occurred when i think qualifying as one of we push towards health care reforms. so join me this morning and welcoming peter orszag. >> thank you all. is a pleasure to be your. i am particularly pleased because i am an avid reader of health affairs, and thank you all for joining us this morning. let me just a few remarks and then i want to reserve most of the time for your questions. we stand on the verge of a dramatic account of schmidt. not only meeting the moral imperatives of the worlds leading economic power, dramatically reducing the reigns 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 health care system of the future embodying continuous improvement and an emphasis on quality rather than quantity. two weeks ago, 23 eminent economists, including the officials who ran medicare under the bush administration, two nobel prize winners and particularly warm to my heart, two distinguished former directors of the congressional budget office, sent a letter to the president outlining the core key pillars of a fiscally responsible health reform and i have that letter within. goes for billers are first, deficit neutrality as gore by the congressional budget office. so that at the very worst, you are doing no harm, doing no harm to our fiscal outlook.

second, the inclusion of an excise tax on high-cost private insurance plans, which according to these economist will, quote, help curtail the growth of private health insurance premiums by creating incentives to limit the cost of plan to a tax-free amount. in addition as employers and health plans redesigned their benefits to reduce health care premiums, cash wages will increase. the third pillar of a fiscally responsible health reform, according to these eminent economist, is the inclusion of a medicare commission which would create a process through which a medicare policy can adopt to changing conditions more quickly than the current system. and as economist know, and i again will vote, creating such a commission will make sure that reform to health care system does not end with this legislation, but continued in future decades with new efforts to improve quality and contain costs. and then finally, the fourth

pillar of a fiscally responsible health reform bill is a series of delivering system reforms. and within that category, i think one should 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 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. in the administration will be coming forth with regulations so that in the near future so that that money will start flowing. and we will be moving towards the digitized system of the future. the second thing in false comparative effectiveness research, that his research into what works and what doesn't. too much of the healthcare services delivered in the united states are not backed by evidence that they work better

than an alternative to getting too many cases, your doctor doesn't have the information necessary to evaluate whether this course of treatment or a bad 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 back that legislation under consideration ads up on that. and then finally, digitize help system what works and what doesn't and then reorienting the payment system a way from paying for more stuff and towards paying for better stuff. right now we have incentives for volume, and that's 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 a delivery system reform one of the continuous feedback with digitize records, evaluation of what is working and what is not, and an incentive for providers to follow and emphasis on quality rather than intensity of. let's take a look at the senator bill, the bill that is on the floor of the united state senate, and evaluate it against those four pillars that have been put forward by the team of economists. first, not only does the build achieve deficit neutrality according to the congressional budget office, it is better than that. the congressional budget office suggested that it will reduce the federal deficit by $130 billion over the next decade. and by a quarter percent of gdp or more than $500 billion over the second decade. so with regard to the first pillar, check that.

second, an excise tax. as you all know, the bill on the senate floor includes an excise tax. on high-cost private insurance plans. check that box. medicare commission. it is also there. check that box. finally on delivery system reform, the senate bill includes new provisions in bundling, and a voidable readmissions to hospitals. that is, roughly 20 percent of medicare beneficiaries are readmitted to a hospital within one month of having been discharged from hospital. no one would ever want to have to go back to the hospital if that's a voidable. because it's not a pleasant experience. and the senate bill includes incentives to try to mitigate that tendency. and also includes incentives to comparative research which i mentioned earlier, including through a new nonprofit institute, to promote quality measurement, to create a system

to pay hospitals based on guy you'd rather than just based on intensity, on volume. to encourage doctors and patients to engage in more shared decision-making, and to create accountable care organizations which have been promoted by a variety of health policy analysts. and perhaps just as importantly, it creates a new innovation center that will allow the testing out of a variety of different approaches, and then moving to scale as one learns what works and what doesn't. now i should say, it would have been a lot easier just to do a deficit neutral bill with savings that are, you know, scored by the congressional budget office and a coverage review. but what that would do is perpetuate a system in which there is inadequate attention to quality and in what you are not dealing with these delivery system reforms. that would have been a lot easier. that was not the course the

president chose and it is not the path that is the house or the senator's biggest remarkable that 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 it looks like it is deficit neutral, or even deficit reducing, that's not the way it's going to be. and the example that is sometimes used is the so-called sustainable growth rate foremen which was put in place in the late 1990s. in which congress has regularly acted to prevent reductions that were scheduled to occur. let me tell you why i think that that line of argument is not apt

to the bills that are currently being discussed. first, unlike the sustainable growth rate -- first, the fact of the matter is that history is not right. if you look at the vast bulk of savings that indent in the past include the balanced budget agreement in the 1990s, the vast bulk of them actually were implemented as opposed to being undone. specifically, with regard to the sustainable growth rate form that there are significant differences between that and the bills under discussion dig up all of the bills did was to reduce, was to have a growth cap on paper and not get as underlying drivers, of health care costs. then press the analogy would have more force. that is not what has occurred. again, as i already said the bills are trying to get at those underlying drivers of health care costs through delivery of system reform that all the other steps we have been discussing. >> the existence of the medicare system which i've mentioned

describes a strong counterweight to any forces to loosen in the future. in other words, medicare commission is on going to be putting forward proposals to improve quality and reduce costs over time. and that provides a very strong counterweight. and finally, don't forget that unlike what has occurred over the past several years, or in the early 2000s, we now have a go provisions that are enforced and that are being obeyed in the house and senate. if you wanted to undo legislation that was enacted this year in the future, under the pay go rules you have to offset the cost of doing that. that was not the case as surpluses emerged in the late 1990s and early 2000s, and those rules were largely ignored. the second critique is that the delivery system reforms, although they are there, are too timid. that there are a bunch of pilot

projects and they're not going to scale the meeting and so ironically on the one hand, some people are saying there's too much been done on the one hand and 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 reignition on unnecessary hospital readmission, or to bundled payments. exactly which condition should be covered, how should the payment structure worked. or with regard to accountable care organizations. again, exactly the parameters that should apply. 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 the media they. so in the income 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 we are trying things and then you have a mechanism in place to move to scale as you are learning what works and what doesn't. the existence of the innovation center and the medicare commission and the senate bill is use that mechanism, where you can go out and try bundled payments. you can try and send us for quality, and a whole writing of other things, and then as you learn exactly what's working and what is not, you go to scale through a process that is already embedded in the legislation. so what you are greeting is an infrastructure for continuous improvement where, again, you have a digitize health care system, researching into what is working and what is not. and then with regard to incentive payments for providers toward quality, you are trying lots of things and you have an ability to get them into practice and into policy much more quickly and deftly and under current law.

so 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 pockets. but the bottom line is, the bill that is curly on the senate floor contains more cost-containment and delivery system reforms in its current form than 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 will get there and i will be delighted to take your questions. thank you very much. >> thank you very much, peter. i will take the moderators prerogative of asking the first question and then we will take questions from all of you in the audience here please be prepared

to invite herself by name and affiliation so we can make sure your last name is not politely. peter, back to the four pillars for a moment. the deficit reduction one, you said being the first, i number have pointed out that a lot of the deficit reduction comes about initially by a class act provisions in the bill, the community living support and services. which essentially is 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 respond to that critique? >> in several ways. first, if not most, it's about half or so of the first decade surplus from the legislation, about 70 billion out of the 130 billion reduction is coming from the class act in the senate

bill, which means that even a part from the class act, there is a surplus contained in the senate bill. second, secondly, even including the classic and the other provisions as you 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 a value weighted to try to make sure that even within that program actuarial solvency is assured and that the program is on a sound financial footing. self containment. and so again, bottom line, even apart from the class act 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 to the. >> what tweaks would've caught that? >> i don't want to get into the

specific details, but there are 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 a tension being paid to make sure this program, the class act, can stand on its own 2 feet am actuarial perspective. >> let's take questions from those of you in the audience. please identify yourself by name. >> two questions. first, former editor in chief of journal of medicine said that single-payer is the single-payer national health insurance, only reform that covers everyone and controls cost that she now leads legislation going through congress should be defeated and we should start from scratch. the second question is the ap reported earlier this week that lobbyists, health care lobbyists

repeatedly over the last year, and you met with the lobbyists from blue cross blue shield association in march, and single-payer advocates have been pretty much barked in the white house that they have not met with decision-makers like a cell. to question. marcia angell's single-payer question, and@@@@@ @ a

broad view sort of 360-degree perspective on health care reform. now with regard to i think the bottom line of your question is is this bill better than nothing for coming, that is a judgment upon which i guess i come down very firmly on the other side for the reasons i have already discussed. not only are you reducing the rates of the uninsured by more than 30 million, let's not forget there are 30 million -- more than 30 million americans who 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 will have higher quality and better insurance with better protection than under current law. and don't forget, that going without insurance is a key driver of personal bankruptcy and you're doing a lot of risk,

financial and other risk when you don't have insurance so that is a major congressman. [inaudible] >> but before, 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. i would just note, i think it was a very good op-ed written by

paul starr, professor of princeton, but been involved in the effort in the early 1990s and who co-founded the american prospect, pointing out that if anything, the attention paid to a public option has been disproportionate to the impact for example, of how the regulations surrounding the exchange would help to promote competition and reduce costs. so the public discussion has become somewhat lopsided, in his opinion, and i happen to agree with him. there are many other things in the additional things that i mentioned that would help to expand coverage, increased competition, and reduce cost. >> let's take another question here. >> thanks. i am filled with kaiser health news. one criticism from the health insurance industry on the individual mandate and the relative weaknesses. $95 worst year, 750 after two

years. why would somebody spend thousands for health insurance as opposed to just paying a penalty? and will that lead to people just waiting until they get sick and then buying insurance? >> look, first one of the things i have learned is that the economy one approach life for all that matters is the direct financial incentive's or penalties is just wrong. so looking at things just so in terms of the financial penalty, not to say that it doesn't matter, what exclusive focus on rational perfectly optimizing behavior is just not, not what is out. if you look at massachusetts for example with a penalty is only slightly higher than $750, they have had if anything much more dramatic take-up than anyone predicted. and that's because i think it is more important that they were advertising at fenway park than the penalty was 900 or 1000 or

$1100. and the reason is it created a social norm that you were expected to have, that everyone knew about it and you're expected to have insurance. similarly, in other areas, if you look at for example the difference between adherence to seatbelt laws and speeding laws, i don't know what your expense is like, i would point out by the way if anything, the financial penalty for -- the financial penalties are roughly the same. a ticket, do not you can for charged with you for not wearing your seatbelt or speeding, roughly the same. i do know about your experience at my expense is that adheres to seatbelt use is much-and here's to speeding laws. and that's because i think there has been, there is to vote in the united states a social norm that you're supposed to wear your seat but if you're driving a car or if you're in a carpet if you got in a car and the driver was speeding i doubt, slutty, maybe 30 miles an hour, 5 miles an hour you would probably want to say something to get the driver wasn't wearing a seatbelt, he would probably --

some of you might say something. and that is the important point. a lot of what the impact of the mandate and other provisions, it will depend on how social norms develop and on execution. and i probably should've said that at the beginning there. one cannot expand coverage by 30 million, move toward higher quality, reduce costs just through legislation, stabbed her fingers and you are 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 with gannett. she isn't convinced yet that the bill would in fact be the

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

>> i think what i will do given the sensitivities of ongoing senate discussions is note there are a lot of those discussions going on and lots of discussion business opt-outs, opt-ins, triggers and leave it at that given that the bill is on the floor and there are many sensitive discussions that are ongoing. >> all right. let's stay in the back and go to the next hand over. it look it's julie. >> i'm from npr and i'm one of five people in this room who are members of the original bras to breakfast. i think our first guest was pete starr.

the congressional budget office and joint task suggested that premiums would not as the insurance industry suggested skyrocket under the senate bill but it also suggested that for most people there wouldn't be very much of an impact on premiums. now the president when he was running promised a $2500 a year decrease in premiums. how is this going to sell and do you agree or disagree with the cbo joint tax assessment of what premiums would do and this, i guess, would be in 2016 under this bill. >> well, there's a few things to note first as you know having read that document for those going into the exchange and are subsidized who are the majority of the folks who will go into the exchange there are dramatic reductions in excess of 50%. i'd also note that -- remember the analysis was done for 2016. it, therefore, does not reflect all of the -- nor in some sense should it because these things take time -- does not reflect

all of the changes that we have been discussing with regard to delivery systems and reforms and those four pillars and what have you. the whole theory of the case here is that the current system is unsustainable. and that you are putting in place an infrastructure so that we can make better decisions in the future and help to move towards quality and lower costs. and i think that's exactly what the legislation is doing. >> all right. let's just come a row forward. you had your hand up right in the center there. >> i'm from cch. you seem to be endorsing whole handedly the senate revenue provision as far as taxing high end health insurance. does that in effect basically write off the house approach? >> i don't know that i explicitly endorsed anything. i think what i said is that these economists have put out the four key pillars and i think

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

made a stirring appeal last night for bipartisanship. the question is, can you or can you tell me what's wrong with the two main republican ideas, one, medical malpractice reform that really sticks and secondly, the ability of people to buy insurance policies across state lines. >> sure, let me deal with that second one first. and actually you know rather than going into a critique, let me just point something out on that and turn to your other question. the folks who say the bills are not doing enough or the savings are not adequate or what have you typically point to cbo scoring and say, the savings are not sufficient or cbo is not able to -- nor should it project forward five or six decades and say this is what's going to transform the healthcare system. and then when pressed, what specifically would you do to make that situation better, the

answers are the two things that you mentioned. being able to purchase insurance across state lines and medical malpractice. so if you hold people to the -- you know, a consistency standard and say, well, what does cbo say about those things? the answer is cbo says both of those things would have very, very modest effects on costs and quality. so just for -- for the sake of sort of intellectual consistency, if you're going to point to cbo and say the bills don't do enough even though cbo suggested that they are deficit-reducing, and then put up those two proposals as the key missing ingredients, you should be willing to live by cbo's analysis of those two provisions and again, they're not overwhelming. i'd also point out as you know the house has a national exchange whereas the senate has a state-based exchange system. in a world in which you had a national exchange as under the

house bill, the ability to purchase insurance across state lines is -- becomes effectively moot. so under the house bill, it's not even really particularly relevant. with regard to your first question, obviously, we'll have more to say about what will be in the budget when we put out the budget. but i would want -- i want to highlight that with regard to moving towards a continuous improvement system so getting in place an innovation center, more comparative effectiveness research, a medicare commission, it strikes me that it would not be practical -- i'm not -- i'm not licensed to practice politics, and you know more about that than i do. it strikes me that it would not be practical to get those kinds of provisions into just an entitlement reform bill. and it will be a remarkable accomplishment if we succeed in

passing this legislation again because it puts in place a structure that allows future entitlement decisions to be oriented towards quality and efficiency in a way that doesn't really exist today. so we'll have a lot more to say we'll have more quantity and not quality. over what time freezing raenvise

have in this country a health system that is efficient and works properly? >> well, i think it's not -- there's not a sort of demarcation point where we declare mission accomplished. it is a gradual process that, you know -- that will be moving forward. [inaudible] >> it will be years to decades to -- but just continuous forward. your doctor in too many cases today does not have any basis -- doesn't have the evidence to know whether this approach or that approach is better. and we need to be reducing the number of situations in which that's the case. >> so can we narrow down years or decades? >> no, the point is -- >> 30 million added to the

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

therefore, it's not -- the reason i'm not giving you a specific answer is, it's just something you have to keep working at. >> spoken like a true middle aged person. >> there we go. >> in the rear, please. >> rich with fox business. >> hi. >> you've talked a lot about the excise tax. it's been weakened a bit in the senate version from what the finance committee had originally come up with. there's some talk about perhaps a different index, maybe to weaken it further. are you comfortable with the level at which that tax sits now or can there be further modifications to it or should it be made stronger? >> i think -- most of the discussion about changes -- well, because it was the main thing that was changed between the senate finance bill and the floor involved the starting threshold. and what's key from a cost containment perspective is the rate at which that threshold is increasing over time. and that was not changed.

and the reason that that's key is what you're doing with regard to how rapidly that threshold is rising is that you're creating an incentive for plans, for employers, to design their plans in such a way that they're under that threshold. and since the threshold is rising less rapidly than healthcare costs, you're creating an incentive -- or healthcare costs without reform, you're creating an incentive to slow the growth rate in private health costs. cbo, for example, suggested that with regard to the people whose plans would be in that zone, you could get a 9 to 12% reduction in premiums by 2016. the result of that is that you shift compensation from health benefit into take-home pay and that's why most of the revenue that is coming from this provision actually comes because

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

plan as opposed to a more moderate cost plan than utilization rates are much higher than that higher cost plan so it's not just that you're sloshing money. it's easy to slosh money around and it's easy to shift money from an employer to an employee. what the evidence suggests is what would happen is the aggregate amount expended on healthcare declines. and that means that the increase in take-home pay in your cash wages is more than sufficient to compensate for any additional healthcare costs shifting and you wind up with more available cash. >> okay. a question back in the rear, please. >> hi, anna with congress daily. there have been some the members, especially, some of those who are still kind of uncomfortable with the bill or want to make som changes who want the administration to say exactly where they stand on some of those differences, public option, employer mandate, do you expect there'll come a time and when, when the administration

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

so people can always complain or question, but judging by results, we are further along and under the leadership of the folks who are running the legislative strategy piece of this, further along than has ever been the case before. >> i'd move over to the other side of the room. let's take a question in the front, please. >> hi, joyce friedan from internal medicine news. the bill puts a lot of emphasis on comparative effectiveness research and getting the most cost-effective treatment for things. and i'm wondering if the uproar over the mammogram and pap smear guidelines has given you any concern about whether people will be able to put in to effect changes that will mean fewer treatment or procedures? >> no. look, i think the goal of the comparative effectiveness or patient-centered health research is to make sure that your doctor

has more information in the future than now on what will work. and the big problem that i see -- there are a lot of cases where the evidence is ambiguous and folks can debate. and i would include the recent discussion in that category. the more important problem from my perspective is there's lots of areas and too much healthcare spending where we simply have no evidence, whatsoever, about whether what's being done is beneficial especially relative to an alternative. and that's where we should be focusing our attention. building out -- let me put it this way. if the problem were that we had evidence on all of the things that were being done and there was that category of ambiguity across the whole array of healthcare spending, that would be a high class problem to have at this point. that's not the main problem that we have. the main problem that we have is that there are lots of things being done where it's not clear what the benefits are and there's no evidence, whatsoever, either pro or con that has

been -- that has been developed. and that's what we need to be doing. >> we'll stay on that side of the room for a moment and take a question right -- in the next row right behind. >> lauren montgomery with the "washington post." hi, peter. >> hi. >> so just as the house rejected the excise tax, if i'm not mistaken they've also rejected the medicare commission. how critical is it that the final bill that has leadership be persuaded to adopt an independent medicare commission? >> well, i don't know i would use the word "rejected" as opposed to not included in their bill. [laughter] >> look, i don't want to get into, you know -- there's a bill on the floor of the senate. the next stage after the senate passes the bill as you know it it will be a conference in between the house and the senate and let's let it play out. >> there are a number of proponents of the commission who think that the version even in the senate legislation has been greatly defanged. if you look at the language it's

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

>> okay. we'll stay again on this side of the room and pick up a couple more questions here and then we'll come back over here. right there. >> hi. i'm with the "l.a. times." there have been some discussion last year perhaps unrealistic that controlling healthcare spending, a key to that would be trying to use money within the healthcare system to offset the costs of paying for a coverage expansion. but it seems, in fact, that the legislation has been going in the opposite direction in some sense. the addition of a medicare payroll tax for high incomed earners. even the cadillac tax is dependent in some sense on the income tax to offset the cost. how concerned are you that given that dynamic that, in essence, we're just pumping more money from outside the healthcare system into the healthcare system going forward and that will only exacerbate the problems of excessive spending? >> well, actually i'd say again taking -- since the one that's

being debated right now, if you take the senate bill, the vast majority of what's happening is that you're taking resources that are already committed to healthcare and redirecting them towards, you know, in various ways. the vast bulk of the savings that are used to finance coverage, more than finance because you have net deficit reduction, more than finance the coverage expansion come from within the healthcare system not only reducing some of the inefficiencies and other things in medicare and medicaid but i would include the excise tax as coming from a commitment of the federal government. basically, it reflects a tax expenditure that is currently devoted to healthcare and it's curtailing that tax expenditure. >> okay. we'll come back over here. take a question right here in the center. >> hi.

doug with american medical news. you spoke a lot in the past about the dartmouth conclusions and how there's potentially 30% of health spending was not effective or was inefficient. i'm wondering over the past few months there's been a scaling back from the dartmouth folks. i'm wondering do you believe that number is a workable estimate or is there some other smaller figure that you think is more realistic? >> well, first i'm not aware that dartmouth even elliott fisher have scaled back the number at all. there was just worth pointing out -- there was a medpac report that came out yesterday that examined the variation in spending and then the variation in utilization patterns. that is, once you adjust for different wage rates and health conditions of the population. and what it definitively

suggested is that although once you control differences in wage rates and health conditions across regions and across parts of the united states, the variation is less. so in other words part of the explanation is that external factors vary.@@@@@@ variation that is not explainable and that is not correlated with outcomes. and, in fact, if anything the higher spending regions seem -- this is worth pausing. we have very significant variation across regions in the united states, across hospitals within a region and even across doctors within a hospital.

and the kicker is that whenever you drill down into any of those levels, the variation of across regions and hospitals and across doctors and try to examine whether for a given type of patient the folks who are doing more spending get better outcomes, the answer is almost universally no. there is a very limited number of exceptions to that general conclusion. and in general if anything the conclusion tends to go the other way. [inaudible] >> my understanding is that -- and again, i'd refer you to the dartmouth folks. i'd point out it's not the dartmouth folks who come up with numbers that are in that range. but also the mckinsey study of cross-country comparisons and frankly the institute of medicine workshop that has examined the potential for efficiency improvements in healthcare. they all are centered around figures in that range. >> i think there may be a

conflation of numbers here, too. the 30% refers to the estimates of the medicine that is of no value. not the variation. the variation is not necessarily 30% -- it's maybe 30% in some is areas with respect to medicare. but it's going to be different if you take into account other data. so i think it's two different sets of numbers there. a question right here. >> hi, susan with reuters. the economy is still struggling and the healthcare sector repeatedly points out how they are one area where growth is a good thing. there's a number of jobs. there's innovation. so how do you -- how do you tackle that? how do you reduce healthcare spending and the costs curve and unnecessary care? how do you factor that against this industry where jobs and the economy is obviously still a huge concern for people? >> well, don't forget, i think whatr we need to do is the sectr needs to be experiencing the

same sorts of improvements that are common in other sectors so that you are orienting again towards outcomes rather than just doing more. in no other sector do you have this -- well, in very few other sectors do you have such strong incentives just for volume. and that is not the right incentive to be giving any market. you want to be providing an incentive for quality, not quantity. and so i don't think this really speaks to the question of the sectors financial health or employment levels but rather what those people are doing. we need to be getting more from the dollars that we're investing in healthcare. >> we'll take a question right here from chuck. >> chuck babbington with a.p. now that there's a bill on the senate floor, i'm wondering what your thinking is about the path to get final passage.

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

financing for the healthcare legislation is medicare cuts to hospitals. and rick pollack of the american hospital association said earlier this week that the coverage levels are not high enough yet to merit cuts of the magnitude that have been proposed. he's talking about a 97% standard of coverage. my question is whether, you know, is that feasible from your point of view financially and if so, how does that get paid for? >> well, look, the legislation does include a very significant expansion in coverage. it's not surprising that various provider groups would prefer to have more people covered and less cost containment. i mean, that's not shocking. but if you look at any of the analysis that has been put forward from medpac or frankly from cbo, what your accomplishing in this legislation is a very significant expansion of coverage without creating significant problems with regard

to access either with regard to hospitals or doctors. so i think i'll just leave it at that. it's not surprising that providers will always want less constraint on their reimbursement rates and more people in their business flow. [inaudible] >> okay. we'll take -- let's take one more question over here and then we'll come back and pick up on final. >> christina with talking points memo. i'm actually curious about former senator tom daschle and former senator ken salazar now secretary of the interior and why the administration is sending them to the hill. if you have -- obviously, you can't talk about what they're saying in these private meetings but why are they doing these negotiations right now?

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@@@@@@ "g a')g

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 13,000 are diagnosed with breast cancer this year so we come to these recommendations made by the united states preventive service task force

and they've made a pretty dramatic statements regarding breast cancer screening .. @@@@@@@ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @@

not necessarily a peer-reviewed scientific journals, but the articles of the day which are of interest to practicing ob/gyn's are discussed in they had a story that ironically was the day before the task force recommendation came out bessette headline breast cancer deaths high gear without routine screening and this was from a report given to the american cancer society in san francisco and a rather startling statistic that dr. katie reported to this group some of the 345 brass cancer deaths which was nearly three-fourths of the total or in women who were not regularly screened. women who work regularly screened had 25% of the cancer deaths. women who did not have regular screening 75% of the cancer deaths. i think that is trying to tell us something and i think again the 2,000-pound gorilla in the

room is the brave new world of health care which congress is going to dictate how things are happening and the recommendations the preventive task force now carry the weight of law if you will under the auspices of the secretary of health and human services or ever they designate, so i think we are having this hearing and i think it is extremely important and extremely timely and i look forward to the testimony of our witnesses, dr. brawley always good to see you and i yield back the balance of my time. >> thank you mr. burgess. the gentlewoman from california, ms. capps. >> thank you chairman pallone ferc holding this hearing. i am so pleased that you and we all have responded quickly to the release of the task force recommendation because there has been a lot of confusion. underscoring the value of having hearings like this in our house

of representatives. i just returned as we all have from our thanksgiving break and i was with my family, and in fact as an aside, receive my own annual during that time. i can assure you that the message is out there but i'm afraid it is not necessarily accurate one so i am looking forward to hearing in greater detail today how the task force arrived at its conclusions and what the recommendations really mean in a practical sense. unfortunately there are people who have completely twisted with the task force is, what the task force does and what its recommendations mean. the scare tactics eyewitnessed have been deplorable. quite frankly the recommendations are based on scientific findings. this is so important to underscore. now we no there is not always consensus within the scientific community where within the advocacy community. both groups so important to us

in setting public policy but we in congress owe it to our constituents and the public to listen to what a reputable group of experts in evidence-based medicine and prevention have to say. for the more we owe it to them to refrain from engaging in partisan rhetoric about what these recommendations mean. the united states preventive services task force issue a whole range of preventive services. they do not make coverage determinations for insurance companies public or private and ultimately all decisions should be made between patients and their health care professionals. the task force's web site of firms their purpose is to present health care providers with information about the evidence behind each recommendation following clinicians to make informed decisions about implementation. at the end of the day this information that clinicians should use to make decisions and consultations with their patients and nothing more. so i look forward to hearing in greater detail what the task force concluded and how they arrived at these conclusions and

i hope it can stop the false accusations. before i yield back i ask unanimous consent to mentor a letter from the partnership for prevention into the record. the partnership is a group of reputable organizations, the american academy of family physicians, physicians' assistants and on and on, there are about ten of them and they are calling attention to our committee on the three most common misstatements that have appeared in the media. when being that's the task force recommends that women aged 40 to 49 not received mammograms. this is the were in the report. the intention was to reduce costs and this is nowhere in their analysis and they are not qualified. these are some of the misstatements in the public that this task force is not qualified to make recommendations are that they have other agendas in play and i asked the letter be made part of the record and i yield back. >> without objection, so

ordered. thank you ms. capps. next is the gentleman from georgia, mr. gingrey. >> mr. chairman i thank you. we have heard already some comments from the democratic side regarding the danger of ignoring signs if we go down that road. i don't think we are talking about newton's third law here by the way. we are not talking about exact science. we are talking i think about an opinion that a judgment is made by the united states preventative services task force, 15 or so members based on looking at a lot of studies. i will tell you as a practicing ob/gyn physician like my colleague from texas, dr. burgess i have spent 26 years practicing medicine. in that specialty i am very proud member of the american college of obstetrics and

gynecology and i am a board certified fellow. we take our recommendations from that organization, and from the standard of care in the community, my community, the greater atlanta area about what our best practices and the american public and particularly the american women, they know who the american cancer society is. they know who the susan g. komen for the cure organization is. many of them helped raise money for that organization by ferry few of them have never heard of the united states prevented the it services task force or in what departments they are embedded and how much power they have and how much authority they may have mr. chairman. they will find out pretty darn soon and i would refer them to pages in both the house and the senate bill, the senate bill for

spending, the house bill 3962 and let them just connect the dots and to see the power that this organization, this u.s. preventative services task force, no matter what they call come to tell physicians basically that this is not an a or b recommendation. this is a c recommendation. if the president had followed through, if the congress have followed through on the present recommendation of having meaningful medical liability reform in these pending health care bills, then maybe physicians like myself would not have to worry too much if we decide to follow the united states preventive services task force guideline cannot order a for our patients between the ages of 40 and 49 or not recommended to them that they do breast self-examination, and we

missed a breast diagnosis of cancer and they died from that disease, or on the other hand, if we decided to ignore the recommendation and we did the and a lump was detected or suspicious marking, the patient had a needle biopsy and it turned out to be benign but unfortunately she developed a breast abscess and then the physician gets sued for not following the recommendations in doing something that is unnecessary. so you put doctors in an untenable position and you put their patients at risk of death so i think-- i can't wait to hear from susan g. komen and the american cancer society and obviously from the preventive services task force and the others on the panel. mr. chairman with that i will yield back. >> thank you. the gentlewoman from the virgin islands, ms. christensen. >> thank you chairman pallone

and given the confusion and the uncertainty with the updated recommendation on screenings by the united states preventive tests scores i hope will bring clarity which i feel is needed on both sides and i thank you for holding it. i've only read the executive summary but i have several questions like why now, did the task force not receive the reaction that has occurred and why was a just released as an article, as important as it is and not as a briefing with present stakeholder organizations? as an african-american woman who has had friends and family diagnosed in their 20s, their 30's and 40's many with no known risk factors, some with good out guns and some a died because of the aggressiveness of the disease and as a physician who came to care very late stage carcinomas like the 24 black women we are going to be reporting on later diagnose in the city in a recent 18 month

period, 24. i am not pleased to say the least with the report not specifically addressing those of us to die most often from the disease. mammograms are not perfect and perhaps lease so in the 40 to 49 each group but as part is the fall armamentarium in the mammogram and a full part of a full armamentarium it is the best we have today. we have never told women that they are all that there is. as ms. deray and dr. brawley will attest our main concern not tb in prevention our main concern ought to be the gaps and out guns and the lack of access to exams and other diagnostic modalities and while this is most evident in the uninsured, co-pays create equal barriers to women with insurance. neither is the federal government doing enough. aetna example the virgin islands scored high on the breasting

cancer exam application but was never funded. and tell everyone has access you can well imagine we will, i will not welcome these kinds of narrow recommendations, what is next colonoscopies training four colon cancer. it probably saved my life in not having one has caused me to lose to many fronts. the task force is dependent which i consider a good thing and it is very important to base recommendation like these on signs but the task force is not as the versus the needs to be to adequately and appropriately address the health care needs of all americans. the recommendations may have been very different orderlies more expensive that some of the recommendations that the american cancer society offered had been accepted. they are similar to ones we recommended for h.r. 3962 i welcome all the panelists and look forward to their testimony.

>> i thank the gentleman. the gentleman from pennsylvania, mr. pitts. >> thank you mr. chairman for convening this hearing. on november 16, the u.s. preventive services task force released an updated brass cancer screening recommendations for women in the general population. several of the recommendations have cents caused widespread confusion and concern. primarily its recommendations for women aged 40 to 49. the task force recommended against routine screening mammography in women aged 40 to 49 based on individual factors should be screened. this is a change from the task force, task forces 2002 recommendation that all women aged 40 and older receive screening mammography every one to two years. the u.s. preventive services task force was first convened by the public health service in

1984 and since 1998 it has been sponsored by the agency for health care research and quality division of the department of health and human services. it is instructive therefore to pay attention to what the secretary of health and human services had to say about the task force recommendations. on november 19, secretary sebelius said, my message to women as simple. mammograms have always been an important lifesaving tool in the fight against breast cancer and they still are today. keep doing what you have been doing for years, takfir dr. but your individual history, ask questions and make the decision that is right for you. basically she told women to ignore the task force recommendations. the good news for women aged 40 to 49 is that they can talk to their doctors and determine whether not routine mammograms are best for them. the bad news is that if the