new recommendations. :

>> to help them make the best choice for them. it also has important lessons for policymakers. one is that the public is ill-served when assessment of clinical effectiveness are politicized. the u.s. preventive services task force is a highly regarded credible and independent group of experts. differences of opinion on the passports recommendations should be openly discussed, but is not constructed to undermine public confidence by making ill-founded attacks on the integrity, credibility, motivations and expertise of the clinicians and scientists on the test for such politicization if left unchallenged could result in future assessments being influenced by political or stakeholder interest in standby science. second, the acp is concerned that the public is misled by some into believing that cost was behind the task force recommendation. according to our, the task force as i consider economic cost and making recommendations.

third, the public need to understand that when health players make decisions on covered benefits, they considered many different issues of which the evidence-based guidelines are just one. under the bill passed by the house, helpless children will be required to cover preventive measures for which a newly constituted task for some clinton services have given an a or a b. no limits are placed on a health plans ability to provide benefits or other preventive services and to consult with other sources in making such determination. rather than limiting access to prevention, my patients will benefit from having a floor, not a limit on preventive services. all health insurers will be required to cover usually with no out of pocket cost to the. and perhaps even more importantly has been said here today many times, millions of women who have no access to health insurance will now have covered and the ability to actually get screening mammograms. forth, we need immediate information to the public in a way that facilitates an understanding of how evidence-based effectiveness reduced support, not to plan for

individual decision-making by patients and their clinicians. they should be informed that they have the right to know about the current best evidence on the benefits and risks of different treatments and interventions. my patients have the right to know that positions will offer interventions, and they have a right to know that we will not recommend interventions show not to provide any benefit and possibly cause harm. patients have the right to be treated as individuals with their own unique value and personal risk characteristics, instead of being asked to follow one size fits all treatment protocols. they have the right to know that the evidence comes from respected, independent and credible clinicians and other scientists protected from political and other stakeholder pressure. and i thank you for this opportunity. >> thank you, doctor. >> thank you. i'm fran visco, president of the national breast cancer coalition and a 22 year breast cancer survivor. as you know, we are a coalition

of hundreds of groups from around the country. dedicated to our mission to end breast cancer. one of our roles is to train advocacy to understand the process and language of scientific research. we analyze scientific information for our members and the public from the perspective of lay advocates that our number one priority for many years has been guaranteeing access to quality health care to everyone. we believe we cannot achieve our mission without a. we have been working with congress and the administration on fiscal based on our framework for access to quality health care, developed over a number of years of hard work by our grassroots leadership and a key component of that framework in making certain that trained, consumers have a seat at every table where decisions are made and health care policy. we believe in evidence-based approach to health as a key to quality care. so what is the evidence behind

mammography screening? as we are all well aware, as many people have said, mammography is sold dedicate limitations and there's been controversy over the years about the screening program. what age are they effective, how do we abounds risk and benefits, how could we can mitigate? the very limited and the harms associated with it. in 1997, and nih conference recommend against routine screening of women under the age of 50, but political and outside organizational pushback, not evidence, torpedoed that recommendation. so in fact we have known issues with screenings for decades but we also know that 40000 women will die of breast cancer this year, tens of of people in this country are uninsured, many, many millions lack access to quality care. we now have a great deal of work to do to fix the situation. we know that breast cancer is a complex disease. while we have learned more about the biology's of the disease, in the four decades since

mammography screening programs have been instituted, we have not yet learned how to detect life-threatening breast cancer at a point where we can make a difference how to cure it for every woman, how to prevent it. given all this, we were frankly stunned at the reaction of the media, and many in the cancer community, and in government to the task force recordation. the task force is a body of the right expert who look carefully at updated evidence, and objectively made recommendations not that different from the prior recommendation. given all of this, the amount of time and attention given to these revised recommendations seems just a bit unseemly. the public has increasingly put their faith in the spring and early detection. even though we have never had good evidence that this would have a significant impact, but too many did not want to highlight the known limitations of mammography. they wanted simple messages. once a year for a lifetime,

early detection, save lives. the over emphasis on the importance of screening cost some people to stay over and over again that mammograms prevent breast cancer. and please, let's be very clear. mammograms do not prevent breast cancer. we hope the recommendation would cause all of the stop and think about screen, take the time to look carefully at the evidence and put the screening and its limitations into proper perspective. that can still happen. it's important also to put this in the context of the population screen chemistry programs are for a healthy population, for the millions and millions of women the vast majority of whom will never get breast cancer. the question then is how we devise a screening program that is appropriate balances risks and benefits with these healthy women. so what did the task force actually say? to women in their 40s, they said there are benefits and harms from a moderately screening that you should know about you and you should make an

individual decision at what age you will begin a screening program. so the task force actually recommends giving women control over their own health care decision. on self-examination, dr. brawley pointed out that the self-examination touched on by the task force is that routine regimented monthly, search for cancer. it has been represented in saying that women should know their bodies. of course they should. this isn't about that. some are concerned that the new guidelines will prevent underserved women from entering the medical system at all, and we would counter that the solution to that is to enact universal access to health care for all. not to depend on a faulty test that exposes women to radiation and the risks of false positives in order to get into a doctor. disadvantage women deserve the same access as all of the women equality, evidence-based care and the right information. we do need to move forward because none of this is good enough for women. we can use this and we should

have used this as an opportunity to educate the public about science, about evidence-based care, to help alleviate unwarranted fear, not to feed it. some argue that public health messages need to be simple and changing guidelines will confuse women. we would argue that while messages need to be simple, they need to be truthful. women deserve the facts. we have all heard from women over the past months who are outraged and to believe that a mammogram saved her life. these anecdotes are not evidence that they may be compelling soundbite great media story, but they are not evidence on which we should base this nation's public health agenda. that should be based on the type of scientific work done by the task force. we can believe in science only when we like the answers it produces. i want to end with an antidote. she was the executive vice president of the national breast cancer foundation at her breast

cancer was detected early in her late 30s. probably was not life-threatening and she had treatment. she died this past june as a result of her treatment. her story and all of these anecdotes just tell us how little we know about breast cancer, how we need to be so very careful about evidence, and push for the right answers, no matter how unhappy we are with what those answers are. let's save our outrage for the realities that we know too little and women deserve so much more. thank you. >> thank you, and we will try to get this done before the vote. i don't know if that's possible. i will start with myself. unit, i really want to apologize to you, you know, maybe on behalf of congress if i could do that. because i was listening to what dr. sweet said, and you're absolutely right. this system is totally politicize and i guess the

problem is congress is political, and maybe this isn't the vehicle for a. i mean, it is sort of interesting to see in the first panel, most of the members of work here and most of the media were here. and now we're on the second panel which is not the political panel, and the situation is reversed, you know. and ms. visco talked about how a sensually, i do want to put words in your mouth, but after listening today, i was -- i can't help but say i'm not sure there really was that much of a difference between what the task force said now versus, you know, what the recommendation was a few years ago, or even between what you're saying and the previous panel said. is just amazing how, you know, these differences, if there are any, have been exaggerated and politicize. i guess that's just the nature of the process around here. i don't know what we can do about it or make it any different. and i say that, you know, out of

sadness really. but let me ask you just a couple of questions, because i know time is running out here. i will start with dr. brawley, and also ms. lurie. a few days after the task force recommendations, the cancer society issued a statement issued health care transparent and evidence-based process of making task force recommendations. and i guess coleman echoed those concerns. but your statement, dr. brawley, listed a number of changes you would like to see in health reform and to discuss the importance of transparency in the task force process of arriving at its recommendations. now, i believe that the bill h.r. 3962, actually addresses those concerns. so i wanted you to really, you know, answer that. i mean, this import and stakeholder input and those recommendations you made about that. does the bill, h.r. 3962,

address those concerns? >> sir, i believe that it does. i think the most important thing is the task force continue to provide objective evidence, but also provide the objective evidence in an open arena where people can actually see the process. >> okay. and then ms. luray, from transcendent perspective, do you agree the provisions in h.r. 3962 would improve the task force recommendations process? you don't have to just say yes or no, but go ahead. >> sir, actually yes. h.r. 3962 has a stakeholder panel that would advise the new clinical services task force. and we think that makes a lot of sense that we think such a panel i think would've helped to really communicate the findings of this task force, even though people might not have -- first amendment disagreement within the scientific community, i think the message could have been delivered in a way that was much more helpful to women and

their providers. >> i want to thank you and i was just time to make the point really that the issue that the american cancer society, komen raised months ago well before these test was recordation's merged, you do, that we felt that on the outside we were listening to and i'm trying to point out that as a result of your efforts in this collaboration, that the bill contains the changes to the task force necessary to improve the process. that was my only point. and in the second one, and i'm going to ask all of you this quickly. and that is, as you know my colleagues on the republican side are repeatedly raising concerns about the house health reform bill in light of the task force recommendations. and they have repeatedly asserted that h.r. 3962 somehow -- i do want to put words in her mouth, but i think there is a suggestion that somehow the bill is a step backward on the issue

of the breast cancer or breast cancer screening. so i just want to add, each of you on the whole, do you think the house passed health reform bill, h.r. 3962, is actually more helpful or is it a step forward or a step backward with regard to breast cancer and the screaming issues? i would just ask each of you to comment on that briefly. >> mr. chairman, if i could just say, there are thousands of american women who died today because of lack of access. there are thousands of women who died today because they are detected early, but they don't have insurance to get access to reasonable and good cheer. any effort that gets those people reasonable and good care is a good effort that is going to save lives. we've been talking about the number of lines that would be lost through this recommendation of maybe it was a recommendation, maybe it wasn't. but the number of lives that we

could just fix, that we could save to a logistical fix is tremendous, just give them access and here. >> ms. luray? >> i would add in addition to the universal access that dr. brawley mentioned, also the limitations on preexisting conditions and out of pocket costs are currently a huge burden for breast cancer patients. and one of the main items that our advocacy community throughout the country asks that we follow very closely in health care reform, and those protections are included in h.r. 3962. >> dr. sweet? think you've. >> absolutely. this bill will help the health of american women with and without breast cancer. there are a number of women who'd managed to get diagnosed and then have no access to reasonable care, as dr. brawley said. the number of women, even in my own practice, that are locked into jobs that they would rather not stay in, they can't move because of lack of health insured ability. they know that if they leave

their job and leave that health insurance when they try to get the next one they will be uninsurable. and i think the fact that this bill addresses getting rid of preexisting conditions and guaranteeing health insurance to all at a reasonable cost is extremely important. and then the third thing is, the bill does address some of the health care workforce issues. access means having a trusted clinician as the woman from florida said. and there are not enough primary care people out there anymore to be trusted clinician for all the people who are going to get access to. and your bill does put in provisions to have an improved, i think, primary work force by approving payment and other things. so i think this bill is an absolute improvement. the millions of lives that we lose because of true lack of health insurance is much, much greater than what we are going to lose by a few women who decide not to have screening once they think about it. >> thank you. ms. visco? >> agile, michigan, the national

breast coalition has addressed the house bill, and we completely support it. we believe it is an incredibly important tool in eradicating breast cancer. we think it will move us forward tremendously. in getting everyone access to health care and helping save lives from breast cancer. and i hope that this controversy does not cause the congress to interfere in any way with the independents and objectivity of the task force. we cannot allow that to happen. we need evidence-based quality care. and i also truly want to ask the question that if the bill was changed to mandate sealevel recommendations for the basic benefit package, if everyone spoke to the issue today, with the support of the. i tend to doubt that. so i really think that if we want to save lives, ever want to move forward, if we want to end breast cancer, we need guaranteed access to health care reform in the house bill is a very important to achieving that end. >> thank you.

let the mention, i was under the impression we had votes that in fact, we are in recess on the floor so there's actually not any time constraints here. chairman dingell? >> i'm going to begin by reading something which appeared in and you'll recognize it and the statements of dr. sweet. under affordable health care for america act, h.r. 3962, passed by the house of representatives, new task force on clinical preventive services would be created which would take on many of the responsibilities of the current u.s. preventive services task force. this new entity will have an important role in making evidence-based recommendations on preventive services that insurers would be required to cover, but the only 19 affect the recommendations of the task force will have on health plans

is is a requirement that preventive measures for which the task force has been given and a or b reagan must be covered. the bill does not get the task force or the federal government itself in the authority to put limits on coverage ration care all require that insurers deny coverage. health plans that offer additional preventive and other benefits of their choosing. and no restriction would be placed on the ability to consider recommendations from sources other than the task force in making such coverage recommendations. now, if you please, starting with you, dr. brawley, do you agree with that statement? >> well sir, i am not a policy person. i am just -- >> yes. spirit but i agree with your statements that i am not trying to lay traps here. ms. luray? >> yes, congressman. as i said my testimony we also

see the role of the task force as grading more of a floor than a seething. so in that sense, i would agree with you. >> obviously, dr. sweet, you would agree. >> yes. [laughter] spirit and i am very good policy people are behind me that agree also. that is important. >> i'm just trying to lay to rest some of the nasty untruths that are being circulated about this legislation. ms. visco? >> yes, i agree. >> now, each of your organizations have supported the legislation, h.r. 3962. do you have any apprehension that the provisions that we are discussing today, or any other part of this legislation, will trigger a nasty program of over rising health care? >> no, sir. >> no, sir. >> no. >> doctor?

ms. luray? >> no. >> mr. chair, i guess that's all the versions i have. i think we have laid to rest some of the unfortunate misapprehensions of our colleagues there and i can only express my great regret that they are not here to participate and to learn from the wisdom of our witnesses. thank you, mr. chairman. >> thank you, chairman dingell. mr. green? >> thank you, mr. chairman. i apologize for being in and out, but we have both secretary gates, secretary clinton and the joint chiefs of staff and the foreign affairs talking about afghanistan. so although this is such an important issue for the district i represent, i represent a majority of hispanic district is also federally medically underserved area. and we face many, many issues and becomes encouraged to encourage women to seek primary and preventive care services. we rely on our parish county hospital district, our health clinics to provide the services of screen for our constituents.

i worry that the revised recommendation will discourage the safety net providers from educating the screening for breast cancer in these underserved populations. i often say what one of the premier medical centers in the world, including the cancer center located in our backyard. but my constituents can see the medical center. it's just hard for them to get it because they are substantially uninjured. and important, unfortunately most of them had access to medical services. could you briefly speak about the current access access berries for breast cancer screening, minority and those residing in medically underserved districts face and what impact these recommendations may have on these populations? dr. brawley? >> congressman, i hope the recommendations of the task force will have very little effect on your constituents, with exceptions for that the

news over the last two weeks will bring breast cancer much more to the forefront. i have some hope, i said in my testament, about half of all women in their 40s and 50s who are diagnosed with breast cancer are diagnosed late traditional example we prefer to call a breast awareness that they notice when they are getting dresser when they are in the shower. that sort of thing. perhaps people will hear what this national conversation had an actually be a little bit freer to come forth and get evaluated by doctors, should they find an abnormality. i also hope that people will continue listening to the other organizations like the american cancer society, that has said that women age 40 and above should continue getting mammography on an annual basis. but also i think it is important to realize that there is controversy about how good mammography is. and i will just leave with one last statement. mammography is imperfect, but right now it is the best

technical tool that we have, other than awareness for early detection. >> mammography is much more valid than the psa test is for males. >> yes, absolutely. you're absolutely correct. there are nine studies in the literature that show that mammography saves lives. there are two randomized trials on psa. one shows that saves lives and another that fails to confirm that first finding. >> congressman, i would like to comment on that as well. as you know, we have partnered closely with the cdc and others providers to support free clinics and moguls in dishes such as yours so we're very for my with a kind of constituents you have. and really i very fragile relationship they have. with the health care system. many of whom are uninsured. and so we've been working very hard in these last few weeks to make sure that the hullabaloo

around the release of this recommendation doesn't cause women who really already have that fragile relationship, who may just be coming into mammography clinics for the first time in their life, to say, well, maybe i don't need to come at all. so we are working very hard to ensure that that message doesn't get twisted around and be taken as a sign that mammography is can provide help to them. >> and i would hope that the clinician doing this, just as in my practice, women will come in talking about it if there is nothing more likely to get a patient to bring something up than to see it on cnn or in a controversial position. and maybe it will sort of nudge many of our clinicians who perhaps haven't taken the time to have that discussion, to actually make an individualized personalize discussion with that woman about what she needs. along with the fact is we said earlier, that many, many, many of those women if health care

reform can occur and we do have access to health insurance for the poor, and the people who need it the most, we will be able to offer screening to some of these women and a clinical situations that have never had that available. so i truly see this as a critical time. and the hullabaloo, it is a political sort of system, and there's a lot of things out there that just aren't true, i think. but it does bring women to discuss its. and once they bring it up then the doctor or the clinician has to follow through. >> thank you. >> we are working very, very hard on making certain that everyone in this country has guaranteed access to quality health care. and that will certainly solve the problem. we are spending the majority of our resources on that issue. there are also a number of studies out there looking at what are the barriers to access for underserved population, why do they not access to health care and served under in system.

one of the reason is they don't have coverage for treatment because why the national breast cancer coalition and number of years ago worked very hard to get enacted into law this cdc press in cervical cancer treatment act because we knew that screening, even if you do get a mammogram, you have to have access to treatment if you want to save a life. and so that is our number one concern. that is where we focus most of our work. >> thanks, mr. terrific i know i am at a time that i appreciate you -- my concerns about the fear over this is that women will make the decision not to come and get early detection is still the answer. and particularly in underserved communities. thank you, mr. chairman. >> thank you, and i think that concludes our questions. i just want to thank all of you again, and you know, once again as i said to the previous banner, you certainly cleared up a lot of the misconceptions. i just hope we can get that message out to the media, which

is often difficult. but thank you. some of the members may submit written questions, and we tried to get those to you within the next 10 days. so you might get some additional questions. of course, the clerk would notify you, and the tiger to get back to us. but i do want to thank you again. and without objection, this meeting of the subcommittee is adjourned agai. [inaudible conversations] [inaudible conversations] [inaudible conversations]

>> american icon, three original documentaries from c-span now available on dvd. a unique journey through the iconic columns of the three branches of american government. see the exquisite detail of the supreme court through the eyes of the justices. go beyond the velvet ropes of public tours and into those rarely seen spaces of the white house. america's most famous homes. and explore the history of art and architecture of the capital. one of america's most symbolic structures. american icons, a three disc dvd set. it $24.95 plus shipping and handling. order online at c-span.org/store. >> the u.s. senate is returning now to resume debate of the health care bill. this morning and will vote on amendments related to preventive health care and this afternoon, another vote, to vote, one on an amendment by michael bennet, and a motion offered by senator john

mccain. live senate coverage now on c-span2. the presiding officer: the senate will come to order. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. our father in heaven, you know all the roads by which each of us has come to serve in our government's legislative branch. you know the pathway our feet now are treading and what the future holds, for you are the architect of our destinies.

give our senators strength sufficient for this day. remind them that their times are in your hands. infuse them with the blessed assurance that you are the love that never forgets, the light that never fails, and the life that never ends. keep them close to you and open to each other, as they do the tasks that preserve our freedoms. we pray in your sovereign name. amen.

the presiding officer: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. the presiding officer: the clerk will read a communication to the senate. the clerk: washington d.c., december 3, 2009. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable kirsten gillibran, a senator from the state of new york, to perform the duties of the chair. signed: robert c. byrd, presidet pro tempore. the presiding officer: madam president stph-p. the presiding officer: the majority leader. -- mr. reid: following reared marks the senate will resuming h.r. 3590. the time until 11:45 will be divided and controlled equally between senator mikulski and the

minority leader or their designees. at 11:45 the senate this morning will proceed to a series of two roll call votes. the first vote will be in relation to the mikulski amendment as modified as to be followed by a vote in relation to the murkowski vote. following votes the time until 2:45 will be equally divided and controlled between senators baucus and mccain or their designees. at 2:45 there will be two votes. all four votes today will be subject to a 60-vote threshold for adoption. mr. mcconnell: would my friend yield before making opening remarks? i was wondering since it is thursday, my colleagues plan to be here saturday and sunday but would phraoeubg to know whether there will be an opportunity to

go to church sunday morning? mr. reid: i think we would come in somewhere around noon on sunday. i indicate to my friend that it appears that we have the -- the next opportunity for amendment will be when we complete this. it's my understanding that senator ben nelson is ready, has an amendment. i think we've given it to your staff. this may be one where it's sponsored by people on your side also. and we'll be waiting to see what your next amendment will be. mr. mcconnell: i would say to my friend, i assume we're going to continue with the procedure that your side offers one, our side offers one? mr. reid: and we will show those to each other before that happens. mr. mcconnell: all right. mr. reid: madam president? the presiding officer: the majority leader. mr. reid: we're in this chamber, and a lot of times we talk it's as if no one's listening to what we're saying, but that's not true. the american people are

listening and they're watching. that's good. but this morning, madam president, i have good news and i have some bad news. the good news is senate republicans finally -- finally -- at long last put a detailed plan down on paper. the bad news is that it's not as we hoped, a plan that will make health insurance more affordable. it is not one to make heurpbs companies more accountable and not a plan to draw down our deficit like the plan that has been submitted to the senate, that is now before the senate by the democrats. again, the plan that we had hoped from the republicans would be that it would be a plan to make insurance more affordable. we wanted to make health insurance companies more accountable, and it would be a plan to reverse the rapid rise in health care costs and draw down our deficit. but, no, the republican plan we've waited weeks and months to

see doesn't do any of those things -fplg in -- things. in fact, it is not about health care at all, even though it is on the health care bill. the first and only plan the republicans bothered to draft is an instructional manual on how to bring the senate to a screeching halt. we knew that was happening anyway, but they had the audacity to put it in writing. here are some of the highlights of this plan: tips on how to force floor reading of all amendments -- long amendments, short amendments. i have no objection to transparency. that's important, madam president. every senator should know what he or she is voting on, but let's be truly transparent. we all know that those who would ask for such readings have no intention of sitting in this chamber and listening to senate clerks. any suggestion otherwise is simply disingenuous.

this document, madam president, explains how to manipulate points of order. and i say that -- manipulate points of order, a complex part of the khrefgt process. yet these senators have no intentions of examining procedures of the senate. the document says in plain language, the whole purpose of this document dated the day before yesterday -- december 1 -- "dear republican colleague" -- and then it sets forth how to slow things down, as if they needed more help to slow things down. 91 times this year they have already done that. but on this bill, this bill affects every person in america, to put in writing they're going to do everything to stop this, to delay this, is really beyond something i think the american people comprehend. the document says in plain language that's their intention. it even condones using this

tactic -- and i quote -- "without cause." do it without any reason, just do it. the rules allow it, so just go ahead and do it. just stall stuff. this letter admits that the goal of this tactic is to delay. i didn't make the word up. it's in here. it's as clear as day. but there's more in this plan. it also advises senators how to -- quote -- "extend consideration of the measure." which motions -- quote -- "again, may be filibustered." and senators might -- quote -- "offer unlimited numbers of motions." well, as we see in the press today anyway, this has caused outrage. it's a catalog of obstruction, a catalog of obstructions to obstruct.

what disappoints me most about this is what isn't here. nowhere in this republican plan is a strategy to lower premiums, not a single word about how to make sphaour more of our -- make sure more of our citizens can afford to stay healthy, can't find one idea of stop insurance companies from denying health care to the sick. madam president, my republican friends have been so busy coming up with games and gambits with ways to distort and delay with scare tactics and stalling tactics that they haven't left time to come up with solutions to one of the most profound crises to the history of our country. the architect behind this blueprint is the senior senator from new hampshire. it is worth noting that this senator, who more than other often speaks properly about how to use citizens' tax dollars has

come up with a plan of wasting time and money. less than two weeks ago the author of this document along with every single of his fellow republicans voted against even letting the senate debate this bill. he didn't even want to give the american people the opportunity to watch this debate take place, to discuss and defend his position. now he expects us to believe his only motive is making sure the minority party's voice can be heard. no one believes that, madam president. because it couldn't be any further from what the founders had in mind. they didn't write this esteemed body's rules so that we could stare at the hands of the clock, which are right up here, as they rotate around each other without end. so let's not pretend the republican strategy is anything different than what it is. after all, republicans certainly aren't trying to hide it. madam president, when i see the kinds of political games, i

think of many cases in nevada, around the country, but i think of a woman from las vegas named alicia. she wrote me a letter when the health care debate was getting underway. she's in her early 20's. i don't know if she's a democrat, an independent, a republican. it really doesn't matter. she was born with a kidney disease, a bad kidney disease. she suffered with it every day of her life, and these days she desperately needs surgery, but she's not going to get surgery. like so many in nevada and across the nation, she recently lost her job. with her job loss, she lost her insurance. she lost her health care. so alicia now went out and tried to buy a new plan to help her afford the care. she can't. no one will give her insurance. can't find a job to have group

insurance. what did the insurance companies tell her -- plural? that her kidney disorder is a preexisting condition. and because of that policy, it's reprehensible of the insurance industry, they refuse to cover. they refuse to cover this young woman at the exact moment she needs it the most. she then tried to go get some help from medicaid, but what is her response? she doesn't qualify because she isn't pregnant and she doesn't have children. and basically, she doesn't have a disability. so, how can you take a woman like alicia out of your mind? i think she's probably following this debate. it means a lot more to her -- this debate -- than the legislative exercise for political objective. she'll pick up the newspaper this morning, turn on the news, go online to read about what's

happening in the senate. why? because it affects her health, her pain and suffering. she probably remembers her grade school textbook teaching her that this is the world's greatest deliberative body and she's eager to find out how those deliberations are going. she's eager to learn what we're going to do with the system that makes it impossible for her to get help. and who knows, she might be watching c-span as we speak. can you imagine being alicia? can you imagine counting on your leaders to right the wrongs we know exist and this is what she finds? a senator writing a letter on how to guide for avoiding tough decisions that may affect her life or may be save her life. we know you don't have to have a bad health history as alicia to have a similar story of your

own. you may have had an accident in your earlier days. you may have diabetes. it doesn't matter. you don't need kidney disease for insurance companies to take away your health insurance. as it stands now, they can deny you coverage because of high cholesterol, because of your allergies. maybe you had minor surgery. or maybe because you're a woman. or maybe your mother had breast cancer. these are reasons they use to deny coverage. insurance companies will use any excuse in the boo book to just say no. for many people in nevada and throughout the nation it is painful, a terrible reality. many oone of the many problems r good bill fixes. i think it is a shameful scheme. the american people couldn't be impressed. they're not impressed. so i can't decide which should disappoint the american people more. the senate republicans are

happily wasting time or that they're so eager to admit it. this is one thing i know: this is no way to govern and legislate and especially no way to lead and no way to lead our country or constituents back to health. the bill before the united states senate saves lives, saves money and saves medicare. mr. mcconnell: madam president? the presiding officer: the republican leader. mr. mcconnell: madam president, this measure was in the majority leader's office for six weeks. its eats only been on the floor of the senate for three days -- it's only been on the floor of the senate for three days. i think it's clear not the case that the republicans want to delay a process that we've only now gotten an opportunity to participate in, since this has been a strictly partisan adventure from the beginning. but we'll have an opportunity over a number of weeks to offer amendments. we're going to have four votes today and hopefully we can proceed pat a more rapid pace than we got off the first couple of days. and of course the reason we

didn't have two votes last night was because there were objections on that side of the aisle. but hopefully we're now into a process where we can go forward without the kind of delay that we had generated by both sides over the last couple of days. yesterday some of our friends on the other side took great pains to explain one of the core pieces of their health care plan. i'm referring, of course, to the massive cuts in medicare they plan to make as a way of expanding government's reach even further into the lives -- more specifically, into the medical care of every american. i have no doubt that our friends were reluctant to call for these cuts. but in the middle of a recession and at a time when more than one in ten working americans is looking for work, it isn't easy to find a half a trillion dollars lying around. they had to find the money somewhere. and so they set their sights on

medicare. republicans have been entirely consistent in this debate. medicare is already in trouble -- already in trouble. the program needs to be fixed, not raided, to create another new government plan. we fought these cuts from the outset and will continue to fight them. democrats, meanwhile, have taken a novel approach, a truly novel approach. they have apparently decided there's no way to defend these medicare cuts, so they simply deny they're doing it. they can't defend the cuts, so they deny they're doing it. it hardly passes the smell test. here are the facts: according to-to-this bill-- -- according to this bill -- this is a fact, madam president -- medicare advantage is cut by $120 billion. madam president, it is a fact that hospitals that treat medicare patients are cut by $135 billion.

madam president, it is a fact that home health care is cut by more than $42 billion. nursing homes are cut by $15 billion, and who is spies -- hospice -- is cut by $7.6 billion. these are the cuts that our friends on the other side claim not to be cut. they're cuts they claim not to be cut. this is a plan that our friends on the other side say will -- quote -- "save medicare" -- end quote. a talking point so plainly and completely coninfrastructure dicted by the -- contra ict dd by the facts it's almost -- contradicted by the facts it's almost impossible to repeat it with a straight face. i mean, this cannot be repeated with a straight face. one democrat took this strategy to a new level yesterday when he declared on the floor that it wasn't even accurate to describe cuts to medicare advantage as

cuts because medicare advantage, he said, is not a medicare program. that was said right here on the floor of the senate, madam president, just yesterday; that medicare advantage walls not a medicare program -- that medicare advantage was not a medicare program. well, that's apparently news to the department of health and -- well, that's apparently news to the department of health and human services that states on its web site in words as plain as the alphabet -- quote: "medicare advantage plans are part of the medicare program." according to the department of health and human services, medicare advantage's plan are part of the medicare program. and it's news to the millions of american seniors who depend on this popular program for their care. at the moment, medicare advantage has nearly 11 million enrollees. looking at it another way, that is one-fourth of all medicare

beneficiaries. one-fourth of medicare beneficiaries are on medicare advantage. and in recent years this program has proven to be particularly popular with seniors in rural areas who would otherwise have limbed access to care -- limited access to care. seniors have shown that they want this plan. they like it. and i dare say that if you had asked seniors earlier this year what they expected health care reform would look like, it certainly wouldn't have involved massive cuts to a program that they've shown they like and they want. medicare advantage has also been proven to help in a particular way low-income and minority seniors. that's one of the reasons minorities are more likely to enroll in it than others. so this program has given a boost to historically disadvantaged populations and given them a greater measure of dignity toward the end of their lives. now, these cuts are bad enough,

but despite what our friends have said, the democrat plan for medicare advantage doesn't stop here. because their bill also gives the medicare commission -- the medicare commission -- explicit new authority to cut even more from this popular program in the years ahead. the president has repeated by said that people who like the plans they have will be able to keep them under his plan. he said, people currently signed up for medicare advantage will have the same level of benefits under his plan. well, common sense, madam president -- common sense tells us that you can't cut $120 billion from a benefits program without affecting benefits. how in the world can you take $120 billion out of a benefit program and not affect benefits? and the independent congressional budget office confirms what common sense already tells us. and they actually quantify it.

c.b.o. says the bill we're debate willing cut extra benefits that seniors receive through medicare advantage by more than half. that's c.b.o. the fact is, cuts to medicare advantage are cuts to medicare. and if it's true of medicare advantage, it's true of other medicare cuts in this bill. deems can deny these cuts all they -- democrats can deny these cuts all they want. america's seniors aren't buying it. now later this afternoon, madam president, we're going to have a bennett amendment -- bennet of colorado has a side-by-side to senator mccain's amendment which would send back to committee the medicare cuts in this bill and ask the committee to report it back without them. so i want to comment briefly on the bennet amendment, and we're going to have nor say about that during the course of -- t more o

say about that during the course of today's debate. the bennet of colorado amendment is a shell game designed to hide the half a trillion dollars in cuts that i've just described. if the bennet amendment passes, the bill will still cut a half a trillion dollars from medicare. let me say that again. if the bennet of colorado amendment passes, the bill will still cut a half a trillion dollar from medicare. it does not protect medicare. there's only one way to protect medicare and that is to support the mccain amendment. madam president, i yield the floor. mr. gregg: madam president, would the senator yield for a question? mr. mcconnell: i would be happy to yield to the senator from new hampshire. mr. gregg: first, the senator is absolutely right to point that the bennet amendment is a shell game, a charade, and a farce. that there will still be half a

billion in the first ten years, but it's actually $3 trillion over the period 2010 to 2029 that will be cut off of medicare. earlier the majority leader came to the floor and said that a memo that i send around -- which was fairly innocuous to our fellly members which outlined the rights of other members with regards to floor activity and most of these issues are tied to the budget, which in the covering letter it said that we as a minority must use the tools we have to insist on a full, complete, and fully inferred debate on -- and fully informed debate on the health care legislation. i would just ask, is it not reasonable that we should have a full, complete, and fair debate on this health care bill? mr. mcconnell: i would say to my friend from new hampshire, we know that this bill was produced by democrats in committee, and then it went to the majority

leader's conference room and stayed there for six weeks. there were no republicans in those meetings, not a one. so after being in the majority leader's conference room for six weeks, it's been on the floor of the senate for three days. this will be the fourth day. to suggest that republicans don't want to offer many amendments to this massive 2,000-page bill that seeks to restructure one-sixth of our economy is nonsense. the american people will not stand for not having a free and open amendment process during the course of this debate, and this is a debate, i would say to my friend from new hampshire, that the american people deserve to have for a considerable period of time. my goodness, we spent four weeks on a farm bill in the last congress. mr. gregg: if the republican leader would yield further, it is ironic, is it not, that the majority leader would come to the floor and complain about an innocuous statement which outlines the rules that members of the senate have, a statement

which i suspect he actually would pass out to his members for information were they in the minority, maybe even in the majority, because they'd like to know how the rules work in the senate, after the majority leader had completely subverted the rules of the senate by not taking this 2,074-page bill through committee so it could be amended in the open, so it could be amended, but rather writing it in the back -- some closet around here with three or four members of the senate present. isn't there an ironic inconsistency to his outrage that we have insisted that people should know the rules here while he has basically tried to go around the rules? mr. mcconnell: well, i would say to my friend from new hampshire, nobody is going to buy outrage over a mere 40 members out of 1 members of the

senate having the opportunity for the first time -- out of 100 members of the senate having the opportunity for the first time to offer an amendment. so not only have they had the bill in their conference room for a six weeks, out here on the floor, they're going to get 60% of the amendments that we vote on. i don't think they'll be ail to convince the american people that somehow -- they'll be able to convince the american people that somehow the 40 of us who are asking for an opportunity to amend the bill is somehow unfair. mr. gregg: i would just ask one more question, because i just find the irony of the situation so unique that a memo which outlines what the rights are of all members -- members in the minority specifically because the rules are meant to protect the minority from the majority; that's the tradition of our government, of course, which seems to be an affront to the majority leader at this point -- that a memo of that

nature, which essentially says the minority has certain rights in order for the institution to function correctly. i'm wondering, why did we create these rules in the first place? wasn't it so that we could continue the thoughts of adams and madison, who suggested that the senate should be the place where when legislation comes forward, which has been rushed through the house, that the senate should be the place where that legislation receives a deliberative view, where it's explored as to its its unintendd consequences and as to its consequences generally and where the body has the opportunity to amend it effectively so it can be improved? isn't that the purpose of the senate? and aren't that what the rules of the senate are designed to do, to accomplish the rules of our founding fathers, to have a senate where legislation is adequately aired and considered as versus being rushed through? mr. mcconnell: it was george washington who was asked, general, what do you think the national is going to be like?

he said, i think it is going to be like a saucer under the teacup and the tea is going to slosh out of the cup into the saucer and cool off. precisely the point my friend from new hampshire raises, which is the senate was a place viewed to be a body that ought to and correctly takes its time. you know, the house of representatives passed this massive restructuring of one-sixth of our economy on one day with three amendments. one day. not the way the senate operates. i can remember when our friends on the other side were in the minority. specifically, i remember the now assistant majority leader saying the senate is not the house. praising the procedures in the senate. and if ever there were a measure -- if ever in the history of america there were a measure that the american people expect us to take our time on and to get it right, it's this one. this massive 2,000-page effort

to restructure one-sixth of the economy and have the government take over all of american health care, where we see in all of the public opinion polls people are saying please don't pass this. they want to try to rush it, try to get it through here in a heck of a hurry, back it up against christmas. and i've said to my colleague, the majority leader, we're happy to be here. we're going to be here saturday, we're going to be here sunday. i did ask for members to have an opportunity to go to church sunday morning if they wanted to, and the majority leader indicated that would be permissible. we have the opportunity to go to church sunday morning, and then after that we're going to be here and vote. mr. gregg: it just seems to me, i suspect that were the majority leader in the minority, he would be insisting on exactly what the republican leader is insisting on: a fair and open debate which allows the minority an opportunity to make its case as to the good points in this bill and the bad points in this

bill. the way you make this case is by following the rules in the senate; is that not correct? mr. mcconnell: the american people expect and deserve no less than exactly what we have been discussing here. madam president, i yield the floor. the presiding officer: under the previous order, the leadership time is reserved. under the previous order, the senate will resume consideration of h.r. 3590, which the clerk will report. the clerk: calendar number 175, h.r. 3590, an act to amend the internal revenue code of 1986 to modify the first-time home buyers credit in the case of members of the armed forces and certain other federal employees and for other purposes. mr. baucus: madam president? the presiding officer: under the previous order, there will be ten minutes equally divided. mr. baucus: i yield myself 2 1/2 minutes from the time under the control of the managers. madam president, for the benefit of all senators, i want to take a moment to lay out today's program.

the time between now and 11:45 is for debate on the amendment by the senator from maryland, senator mikulski, chairman of the subcommittee on retirement and aging of the health, education, labor and pensions committee. and at the same time we'll debate the side-by-side amendment on the senator from alaska, senator murkowski. at 11:45 the senate will conduct two back-to-back roll call votes on the two amendments. first on the amendment by the senator from maryland, and second on the amendment by the senator from alaska. thereafter, we will conduct approximately two hours of debate on the mccain motion to commit on medicare and the side-by-side amendment by the senator from colorado, senator bennet. at 2:45 the senate will conduct two back-to-back votes on the amendment by the senator from colorado followed by a vote on the motion to commit by the senator from arizona. thereafter, we expect to turn to

another democratic first-degree amendment and another republican first-degree amendment. madam president, this is the fourth day on this bill, and we're only late this morning coming to our first vote. even for the united states senate, this is a slow pace. i note that some have made plans for delaying this bill even in a more extreme fashion. as the majority leader noted earlier today, on tuesday one senator circulated a list of delaying tactics available under the senate rules. i presume that all senators know the senate rules already. so to send that letter to me, i think, leaves the impression that that senator would like to urge senators to use some of those delaying tactics stated in that memo. but i urge a more cooperative

course. out of courtesy to other senators who desire to offer amendments, i urge my colleagues to allow us to reach unanimous consent agreements to order the voting of future amendments in a more timely fashion. that's simply the only way that we can assure more colleagues will have the time and opportunity to debate and offer their amendments. and i thank all senators. madam president, i have a couple of unanimous consent requests. first, i ask consent that stacy sax, floor privileges. consent that stacy sax, a detailee in the senate "help" committee, the majority "help" office be granted floor privileges for the duration of h.r. 3590, the patient protection act. the presiding officer: without objection. mr. baucus: madam president, one more consent which i am told has been cleared by both sides. i ask consent that the order of december 2 be modified to delete

all after the word "table." the presiding officer: without objection. mr. baucus: i now ask consent that debate time from 2:00 to 2:45 p.m. this afternoon be divided as follows in the order lists. the first 17 1/2 minutes under the control of senator mccain or his designee. the next 17 minutes under the control of senator baucus or his designee. and the final 10 minutes, 5 minutes each to senator mccain and senator bennet from colorado. the presiding officer: without objection. mr. baucus: i thank the chair. a senator: madam president? the presiding officer: the senator from iowa. mr. harkin: madam president, i heard the distinguished minority leader earlier this morning in his comments say that one of the reasons they're kind of slowing this bill down and having all this debate is because it's been -- and i quote his words -- a strictly partisan venture thus far. well, i beg to differ with the minority leader. i see our distinguished ranking member of our "help" committee here on the floor. in the "help" committee -- in

the "help" committee -- let me just again for the enlightment of senators -- we had 13 days of markup, 54 hours, 788 amendments were filed, 287 amendments were considered and debated and voted on or accepted, 161 republican amendments were adopted. 161 republican amendments were adopted. no one was denied the opportunity to offer any amendment, to discuss it and debate it and get a vote or get it accepted, whatever the case might be. to me, this is truly a bipartisan way of proceeding. it seems to me the minority leader, his argument basically goes to the fact that the people of this country overwhelmingly elected democrats to guide and make changes for the future. and one of the biggest changes is in our health care system. and so, one of the

responsibilities of being in the majority party is to propose. that's what we've done. we are proposing changes in the health care system in america. it seems to me the function of the minority is to offer amendments, instructive amendments, offer different ideas. and if their ideas are better or gets the majority approval, then the bill is thus changed. and that's happened in our "help" committee. as i said, 161 republican amendments were adopted. to me, that is bipartisan. and that's what we've been doing. but what is kind of not acceptable is this idea that things are just going to slow down for the purposes of delaying and eventually making sure that we don't have a bill. well, let me just say that after all that lengthy debate we had in the "help" committee, we passed a bill. the same will happen here on the senate floor. i don't care how many times the minority wants to drag it out

and slow it down and try to kill this bill, this bill will pass the united states senate, will go to conference, and we'll have it on the president's desk early next year. mr. enzi: madam president? the presiding officer: the senator from wyoming. mr. enzi: i appreciate the comments. some need correction, some from yesterday and some that have just been made. on a partisan bill, i sat through all those days in the "help" committee. that bill was rushed and put together. senator kennedy was not able to be involved in that part of it. his staff did it. they did it in a hurry. we turned in 161 amendments that were accepted. most of those were for typos and minor corrections. now there were a few of them that actually had some substance to them. that bill was passed on june 17 in committee without a single republican vote. it wasn't published. we didn't get to see the final version of that until september 17. you know what?

the ones that were really something that could have made a difference were taken out without the permission of any republican senator. that's not bipartisan. we talked about how many hours we spent together. if you don't accept things from the minority party, it's not bipartisan. it's still partisan, just spending hours doesn't make any difference. to move on to a different topic, yesterday we were talking about costs. i hope that people take a look at a "wall street journal" article from yesterday that says that the bill that raises prices but lowers costs does other miracles. we heard all day yesterday that this bill is going to save people a lot of money. well, this article says we've now reached the stage of the health care debate when all that matters is getting a bill passed. so all news is good news. lower subsidies means lower deficits. the nonpolitical mind reels.

consider how w-sz received the congressional budget office monday about how harry reid's bill will accept insurance costs which by any rational measure ought to have been seen as a disaster for the bill. c.b.o. found premiums in the individual market will rise by 10% to 13% more than if congress did nothing. family policies under the status quo are projected to cost $13,100 on average, but under the bill we're looking at it will jump to $15,200. fabulous news. no big cost rise in u.s. premiums are seen in the study said "the new york times" while the "washington post" declared senate health bill gets a boost. the white house crowed that the c.b.o. report was more good news about what foreman will mean for families struggling to keep up with skyrocketing premiums under the status quo.

max baucus said lowering costs is what health care reform is designed to do. lowering costs will achieve its objective. except it won't. c.b.o. says it expects insurance costs to remain roughly in line with the status quo. yet even this is alurere by mr. baucus' and the white house's standards. meanwhile fixing the market which is unstable largely because it does not enjoy favorable tax treatment given to the job base coverage was supposed to be whole purpose of reform. instead c.b.o. is confirming the new coverage mandates will drive premiums higher. the democrats are declaring victory, claiming these higher insurance prices don't count because they'll be offset by new government subsidies. about 57% of the people who buy insurance through the bill's new exchanges that will supplant today's individual market will qualify for subsidies that cover about two-thirds of the total premium. the bill will increase costs but it will disguise these costs by

transferring them from taxpayers to individuals. higher costs can be conjured away because they're suddenly on the government balance sheet. the reid bill's $371.9 billion in new health taxes are also apparently not a new cost because they can be passed along to consumers or perhaps hidden in lost wages. this is a paleo liberal school of the distribution and a long way from the rao*e peteed white house claim that the cost is about bending the cost curve. c.b.o. is almost certainly underestimating cost increases based on county by county actuarial data, the well point has said mr. baucus will cost some premiums to triple in the individual market. i've seen what is going to happen in wyoming. the bluecross blueshield came to similar conclusions.

c.b.o. doesn't think this has much effect, but costs inevitably rise when insurers aren't allowed to price based on risk. we have 35 states that give an example on that. but the white house decided to shoot the messengers like well point to avoid rebutting their message. but amanda kowalsky of michigan found similar results in a -- of m.i.t. found similar results in a peer paper. economists found state community rating loss raise premiums -- the presiding officer: the senator consumed five minutes. mr. enzi: i'd ask the remainder of this editorial be published in the journal. the presiding officer: without objection. mr. enzi: i yield the floor. the presiding officer: under the previous order, the time until 11:45 a.m. shall be equally divided between the senator from maryland,

ms. mikulski, and the republican leader or their designees. the senator from iowa. mr. harkin: parliamentary inquiry. there's time now between now and the hour of 11:45, equally divided between the republican and democratic side; is that correct? the presiding officer: correct. mr. harkin: then i assume the thing will be to go back and forth between one side and the other, republican and democratic side? the presiding officer: that will not be an order unless it's propounded. mr. baucus: i think it's very well understood. mr. harkin: madam president, i ask to be he can ared for -- i ask to be recognized for seven minutes. the presiding officer: without objection. mr. baucus: will the senator

yield for just a quick inquiry to my friend from wyoming. i might inquire of my friend from wyoming, that article that the senator from quoting from about the costs in "the wall street journal," was that a news article or was that an editori editorial? mr. enzi: it was confirmed by m.i.t., brigham young, and others. mr. baucus: thank you. the presiding officer: the senator from iowa. mr. harkin: if the chair would remind me when that seven minutes is up. i wyou mentioned that we had doe the bill in a hurry in our committee. actually it was last november shortly after the election that i received a call from senator kennedy talking about doing a health reform bill, asking if i would take charge of section dealing with prevention in

public health and wellness. i think then he asked senator murray to take over workforce development. senator bingaman did coverage, and senator mikulski did quality improvements. so that was in november. after that, i can't speak for the other -- others that did the other sections -- you will i ca- --all i can say is on our side and what i did. we had five hearings on public health and prevention and wellness and what ought to go into a bill. those commenced in november and went through i think about february. and then we worked until june. we didn't start our markup until june. so we had almost six months of hearings and putting things together in the bill before we started markup. i rather doubt that that can be said to be rushing anything. but, madam president, i just want to focus on the vote that's coming up on the amendment offered by the senator from maryland, senator mikulski,

which will strengthen provisions in the bill concerning preventive health benefits for women. as an initial matter, i'm proud of the significant investments this bill makes overall in wellness and prevention. it's not been talked about very much. if you read the public press out there, the popular press, and watch tv, abouthe only thing you think that's in this bill is a public option and abortion. that's what this bill is about. well, those may be the mott points, the -- well, those may be the hot points, the flashpoints. but i submit that the most important part of this bill is what it does for prevention and wellness. trying to move our costs upstream, keeping people healthy in the first place. i've said many times what good does it do us if we're just going to pour more money into paying bills for a broken, dysfunctional sick care system? not a health care system, a sick care system. that's what we have in america

today. this bill begins the transformation of moving us from a sick care system to a true health care system. and the senator from maryland has a very important amendment to make clear -- to make clear -- that what is included in this bill is to strengthen the preventive services that basically inure to the women of this country. mikulski's amendment reiterates the recommendations of our bill, and it also points out that the recommendations of the united states preventive services task force is a floor, not a ceiling. it is a minut minimum. in other words, health plans are required at a minimum to provide first-dollar services recommended by the preventive services task force.

but that's just the minimum. the secretary of health and human sstleses has full discretion to advise additional preventive services that will be part of the essential package offered by health insurance on the exchange. now, again, there's been some talk here about this task force, the preventive services task force, that somehow this is a bunch of bureaucrats, it's government-run task force, it has a political agenda -- i've heard all these things said on the floor the past day or soavment it is an independent body that evaluates the benefits of clinical preventive services. it makes recommendations -- again, no decisions, just merely recommendations -- about which services are most effective. well, who's on this task force? well, experts and leaders in primary care who are renowned internists, pediatricians, family physicians,

gynecologists, obstetricians, and these professionals are not located in wawshtd. they're based -- and these professionals are not located in washington, d.c. they're based all over the country. and they are the experts in these different areas, recognized by their peers. they don't sit in an office at health and human services. they bring years of medical training and experience to the jobs they do. now, does that mean that mista? no. no one is perfect. no senator is perfect. neither is every doctor perfect. and neither is any task force going to make what we might consider to be the perfect answer. but our bill does not grant the authority to tell insurance companies what not to cover. that's clear. but to hear the debate on the floor, you'd think it was just the opposite that the preventive

services task force can tell insurance companies what they cannot cover. that's not true. our bill says that those recommendations that are "a" and "b," categorized by the preventive services task force buby these expert doctors around the country, these are the ones they say really are key preventive services, have the most benefit. we say that, in our bill, that those services must be covered, without co-pays, without deductibles. that means that's the floor. that's the floor. now, again, i might also add that preventive services that are rated by the advisory committee on immunization are also part of the recommendations to establish that floor. so again i would say it is a pretty big floor.

when you put all those together. now, -- so again it does not establish a ceiling and it doesn't say what can't be done. it just sayit just says, you goo these basics. that's the floor. i do understand the concerns that the preventiv preventive pe has not spent enough time studying issues related to women. senator mikulski pointed out to me when i was the chairman of the appropriations committee that funds n.i.h. -- the presiding officer: the senator's time has expired. mr. harkin: i ask for three more minutes. the presiding officer: without objection. mr. harkin: senator mikulski said, you know, if you look at the research being done at n.i.h. it's done almost all on men and not on women. i remember that. i said, you're rievment so we had to -- i said, you're right.

so we had to start focusing on the unique situation faced by women. well, this was also a concern that raised in our "help" committee by senator mikulski, and we included language to require all health plans to cover comprehensive women's preventive care and screenings. based on guidelines pom mule debated by -- promulgated by the administration, again without any co-pays or deductibles. that was unfortunately not included in the merged bill. but senator mikulski's amendment, which we are about to vote on, brings us back to the position that we had on the "help" committee bill. that was largely, i think, supported, if i am not mistaken, on both sides, at least in our "help" committee. at least no one offered any amendment to strike it. when we were debating it in committee. so i assumed it was supported generally by both republicans and democrats. so by voting for the mikulski

amendment, we can make doubly sure that the floor that we're establishing in this bill for preventive services that are unique to women also have no co-pays and no deductibles. and, again, that's why this amendment is so, so important. now again, i know that our friend, senator murkowski, has a different way of approach. i commend her for her involvement and her interest in this. she has a great member of our committee, and i've done a lot of great work with senator murkowski, but, again, i think her amendment misses the mark in this way: it asks insurers to use guidelines from provider groups when making coverage decisions. well, that does not guarantee that women will get any of the preventive services they need. it says -- and i will -- here's a statement here from the american heart association and the american stroke association

that says, "we are concerned that senator murkowski's preventive service healths amendment would take a step backwards by substituting the judgment of the independent u.s. preventive services task force with the judgment of private health insurance companies." and i ask that this letter from the american heart association, this statement be made a part of the record. the presiding officer: without objection. the senator's time has expired. mr. harkin: i'll have more to say about the murkowski amendment later. the point is the mikulski amendment is right on point. it should be adopted. the presiding officer: who yields time? mr. enzi: i yield to the senator from florida. mr. harkin: madam president? the presiding officer: i made a mistakes. i meant the mikulski amendment to be adopted. the presiding officer: i know. the senator from florida. mr. lemieux: madam president, thank you. i come to the floor to talk

about the issue of the bill before us, not just on this particular amendment, but on what it's going to mean for my constituents in florida and for the people of this country. madam president, i had the opportunity last week to be back home in florida in palm beach county, in broward county, in miami-dade county, where i talked to doctors, hospital administrators, folks who run medicare advantage plans as well as everyday floridians, spheskly senio--specifically senior citi. and the responses i heard were nearly unanimous. that grave concern about the bill that's being debated on this floor and a general confusion as to why the congress is pursuing on the path that it is. the people of florida don't understand why we're going to cut medicare to create a new program. the people of florida don't understand why we're going to raise taxes to cut a -- to create a new program.

the people that i've spoken to in florida do not understand why we would undertake a new $2.5 trillion health care proposal if it wasn't going to reduce the cost of health insurance for the 170 t million to 180 million americans that have health insurance today. why are we embarking on this measure if it is not going to affect most of everyday floridians and everyday americans who are struggling under the high cost of health insurance? health insurance premiums are increased 133% over the past ten years whvment the president put this issue forward and when he campaigned on it, he said that his major goal was to reduce the cost of health insurance. when he addressed the nation in a joint session of congress on september 9, he said that his plan would reduce the cost of health insurance. but we find out for at least 32 million americans, it will raise the cost of health insurance 10%

to 13%. so at least half of the goal, if not most of the goal of this plan for most americans in this country will not be accomplished. we're going to raise taxes by a half a trillion, and we're going to spend $2.5 trillion on this program, which was admitted to by senator baucus yesterday on the floor, which cannot be budget-neutral. madam president, i want to speak specifically about the cuts to medicare. $192 billion congress according2 billion according to the congressional budget office to medicare services. if you cut providers, you are going to cut services. the very reason we talked about increasing doctor payments in that quarter of a trillion

dollar program was so that patients wouldn't receive less services, so that there would be ample doctors providing sstleses for medicare. it is beyond logic to argue that cutting providers will not cut services. and what will happen when we cut providers, doctors, nursing homes, home health agencies, hospitals? less and less of them will provide benefits and less and less of them will take medicare. the chief actuary of c.m.s. believes that the cuts in the bill that we have before us will for providers constitute a substantial portion of their business, and they could find it difficult to remain profitable and might end their participation in the program. i mean, every american understands this. if we pay less money to health care providers, they're going to offer less benefits or more and more they're not going to participate in medicare.

the medicare payment advisory commission found in june of last year that 29% of medicare beneficiaries who remember *f who were -- who were looking for a primary care doctor had a problem finding one to treat them. this is of grave concern to the 3 million floridians who are on medicare. if a doctor won't see them, what kind of health care plan is this? these seniors, our greatest generation, have paid into this program their whole life, and it is i will illusory if they can'a doctor who will treat them. one of my constituents, earl bean, from sanford, florida, recently told cnn that he called about 15 doctors when he was trying to find health care, and he was told they're not taking new medicare patients. so when we cut $500 billion out of medicare, is that going to improve heal care for seniors or is it going to continue to decline health care for seniors? you can't get blood from a

stone, madam president. it's going to make the situation worse. and for anyone to come to this floor and say that it won't is incredulous. we have the second-highest medicare population in florida. and when we cut $135 billion from hospitals and $21 billion from the disproportionate share fund, which is basically money that goes to these hospitals to provide health care for seniors and the indigent, how are they going to be able to provide that health care? i spoke to the administrator of the north broward hospital district and told him about this cut to the dsh funds, and he told me it would be devastating on their provision of health care. and then we're going to take a very popular program called medicare advantage, more than 900,000 floridians in my state, and we're going to cut it as well. i recently visited the leone medical center in miami dade

county where they're providing state-of-the-art first-class health care for seniors. eyeglasses, hearing aids, dental care. the constituents that go there, they love it. they're getting the kind of health care that you would hope your senior citizens in your family would get. and the principal of the company has told me they saved $70 million in the way that they've run their system. and he told me that if we continue on this path with these cuts to medicare advantage, he will not be able to provide these good services going forward. now there are some fixes to grandfather folks in, but all in all people will be cut and all in all the program will not be as good and it will decline the health care of seniors in florida and across this country. we will cut $15 billion from nursing home care, $40 billion from home health agencies. i spoke to a provider of home health agency practice in

florida, he said that these cuts will put half of the home health agency folks out of business, at a time when we have 11.2% unemployment in florida, this health care bill is going to cost people their jobs and it's going to decline the quality of health care. i'm also concerned about this medicare advisory board. this independent board of nonelected folks are going to have the power to cut medicare by $23 billion over the next ten years, and it will be up to this body to reinstate those cuts. these people are not elected. my constituents in florida don't know who they are. but they're going to be responsible for the decline of their medicare and their health care. the greatest generation fought to protect this country is looking at this health care bill and wondering why.

folks with health insurance in this country, more than 170 million, who are not going to see their health care costs go down, but up, are wondering why. americans who are seeing higher taxes and penalties for not buying these health insurance programs under this bill are wondering why. if we're here to reform health care -- and we should be -- if we're here to try to make sure that the 45 million in this people and the nearly 4 million floridians get hlth insurance -- and we should be -- then why don't we take a step-by-step approach? madam president, i am new to this body. my first day here was september 10, so i've not even been here three months. but i can tell you that the american people would, if they knew what i know now and could see what i see, they'd be baffled by this process. there is not a give-and-take on this. we didn't all sit down together in a conference room and work

this out to have a bipartisan bill. the leader, the democratic leader, worked on it with his colleagues but not with us. so now we have a program that cuts medicare, that raises taxes, that doesn't decrease the cost of health care for the majority of americans and will cost us $2.5 trillion and can't be budget-neutral at a time, madam president, when we have a $12 trillion debt, a debt that requires each of us, each family to put $100,000 on our shoulders to be responsible for that debt, a debt where the third-largest payment in our budget is for interest payments and in the next ten years those interest payments will go up by $500 billion, enough to pay for many of the budgets of the federal government -- the presiding officer: the senator has used his ten

minutes. mr. lemieux: i thank the senate and i yield the floor. the presiding officer: the senator from maryland. a senator: how much time does the senator want? the presiding officer: the senator from maryland controls the time. the senator from maryland has 33 minutes. ms. mikulski: madam president, i yield myself a firm ten minutes. the presiding officer: without objection. ms. mikulski: madam president, health care is a woman's issue. health care reform is a must-do women's issue. and health insurance reform is a must-change issue. so many of the women and men of the senate are here today to fight for change and to make sure that we have universal access to health care. and when we have universal access, that it makes a

difference in our lives, which means that we have to have universal access to preventive and screening services. what my amendment does -- and, by the way, it is a bipartisan amendment -- is makes universal access to preventive and screening services for women available. now, there's much discussion about whether or not you should get a particular service at a particular age. we don't mandate that you get a service. we leave that up to a decision made with the woman and her doctor. but, first of all, you need to be able to have a doctor. so we're for universal access, and this is why the underlying bill is so important. and then when you have that, that there also be universal access to preventive and screening services, particularly to the top killers of women,

those things that are unique to women. if we take cancer, we think about breast cancer, ovarian cancer, and cervical cancer. also women are dying at an increased rate of lung cancer. then there are these other silent killers that come and have had a lethal effect on women. and that's cardio and vascular disease. so we want to guarantee universal access to medically appropriate or medically necessary screening and preventive services. now, many women don't get these services because, first of all, they don't have health inrance. and, number two, when they do have it, it means that they either -- these services are not available unless they're mandated by states or the co-payments are so high that they avoid getting them in the first place. the main thing about the -- the

second main thing about my amendment is that it eliminates deductibles and co-payments. so we eliminate the biggest hurdle, two big hurdles: one, having insurance in the first place, which is the underlying bill. and also co-payments and deductibles. i know of no one in this room who would not want to be on our side on this issue. i want to acknowledge the role that the gentlelady from alaska has played, senator murkowski, senator kay bailey hutchison, senator snowe and senator collins. we, the women of the senate, have worked on a bipartisan basis for years, making sure we were included in the protocols at n.i.h., increasing funding for important research areas to find that cure, to race for that cure, and at the same time to be able to have mammogram standards. what the gentlelady from

alaska's amendment does -- and, by the way, she's murkowski. i'm mikulski. we sound alike and the amendments might sound alike, but, boy, are they different. murkowski offers information. i think that's important. that's a threshold thing. you have to have information to make an informed decision. but it does not guarantee universal access to these services. and, of course, it does not -- and it does not eliminate the high payments and deductibles. so, her amendment is flawed. my amendment is terrific. my amendment offers key preventive services, including an annual women's health screening that would go to a comprehensive assessment, including the dangers to women in heart disease and in diabetes. we would hope that when the senate makes its decision today,

it deals with the fact that for we women, the insurance companies also simply take being a woman as a preexisting conditio we face so many issues and hurdles. we can't get health care. we can't get health insurance because of preexisting conditions called a c-section. i'm going to be meeting with an insurance company executive later where his company, denied health insurance to a woman who had a medically mandated c-section and a letter from this insurance company said we're not going to give you insurance unless you have a sterilizeation. a coerced sterilization in the united states of america. madam president, that's going to be an amendment for another day. but i just want to give the flavor and the power of what women face when we have to cope with the insurance companies or where there are barriers to our

getting these health care issues -- health care screening services. so we want to be able to save lives and we want to be able to save money. we believe universal access, and if you utilize the service it's because you've had the consultation with your doctor. and at the end of the day, because we do know early screening and detection does save lives and at the same time it saves money. and i'll conclude if we look at heart disease and diabetes, not only cancer, early detection of diabetes means that in a well-managed program, under appropriate medical supervision, you very likely will not lose that eye. you will not lose that kidney. you will not lose that leg. and most of all, you will not lose your life. so let's not lose the mikulski amendment. let's go with mikulski and thank murkowski for information, but hers is too tepid and too

limited. madam president, i yield the floor. madam president, i ask my colleague, one of the great guys who support us, senator cardin, how much time we have. five minutes to senator cardin. the presiding officer: the senator from maryland. mr. cardin: first let me thank my colleague, senator mikulski, for her leadership on this issue. i strongly support her amendment for the reasons that she said. this is a very important point about providing preventive health services to the women of america, a critically important part of our strategy not only to bring down costs in health care, but to have a health care system that is fair in america. and, madam president, i've been listening to my colleagues on the other side of the aisle talk about the underlining bill. they talk about it as if this is a static situation. many of the criticisms i hear about the underlining bill are criticisms about our current health care system.

i can tell you people in maryland, many of whom are finding it difficult to find affordable coverage today and are outraged what's happening with the private insurance companies, the attitude they're taking as senator mikulski pointed out, denying coverage on preexisting conditions or posing arbitrary caps. as has been indicated, if we're unable to get this bill passed, what is going to happen in the future? insurance companies are going to continue their arbitrary practices and the health care of americans are in jeopardy. we're already spending so much of our economy on health care, if we don't take action, it will ago greater part of our economy. but we have some good news. the yowndz lying bill has now been analyze -- the underlying bill has now been ogeized by the congressional budget office. that's the independent scorekeeper. if we pass the underlying bill, for the overwhelming majority of americans, they're going to find that their health insurance premiums will either stay the same or go down.

and for the overwhelming majority of americans, they're going to have a better insurance product that's going to cover the types of preventive services that senator mikulski is talking about, that's in her amendment. so we're not only going to bring down the cost for the overwhelming majority of americans, we're going to provide better coverage for those americans. the underlying bill will also reduce dramatically the number of people that don't have health insurance in america by 31 million. that's going to make our system much more effective. i've heard my colleagues talk about what's going to happen with medicare. if we passed underlying bill, we're going to strengthen medicare. we already have a provision that we pointed out, that there can't be any reductions in the guaranteed benefits. we already pointed out that aaraarpendorses the bill. we've already pointed out there that wiltherewill be additionalr

medicare. it will also bring down the cost of health care. when you reduce the number of uninsured ukes the amount of cost that medicare has to pay for health care in our hospitals is reduced. that's why we can reduce our payments to hospitals in america because the amoun of uncompensated care they currently have will be reduced. i have heard my colleagues on the other side of the aisle talk about medicare advantage. let me tell you something. i remember when we used to pay the private insurance companies in medicare a little less than what we paid people in traditional health care. that's corporate welfare, we're paying them the same. taxpayer support is higher than what it used to be. we know that these benefits that are being paid could be gone tomorrow. we saw it happen. we saw the private insurance companies leave the maryland market, leave so many markets.

so these are reforms that save the taxpayer money and strengthen medicare for the future. bottom line is the bill is good for middle-income families. it will provide the insurance reforms so that they have an insurance product that can cover their needs, including the wellness and prevention programs. it's good for small business because it offers more choice and i could tell you chapter and verse of small companies in maryland who today cannot get an affordable product, who are seeing a 20%, 30% increase in the premium. they need this-to-in order to preserve health care for their -- they need this in order to preserve health care for their employees. it will reduce costs and improve quality and will make our health system more efficient and effective for the future, bringing down the costs by investing in wellness and prevention. i urge my colleagues to support the mikulski amendment. i urge my colleagues to support the underlying bill. with that, madam president, i

would yield the floor. the presiding officerthe preside senator from south dakota. mr. thune: thank you for yielding. i appreciate the opportunity to speak on this important piece of legislation. i want to again point out to my colleagues and to anybody else who may be observing the volume of this thing. this is 2,100 pages. 21 pounds, which means it is about a pound per 100 pages. it is $1.2 billion per beige, $6.8 million per word, creates 78 new government programs and gives the secretary of health and human services in 1,700 indenses in this bill the opportunity to create, define and determine things in this bill. this is a big government bill, a massive expansion of the federal government, $2.5 trillion when it's fully implemented. now, of course to pay for all of

the sthings i things in this biu have got to have revenue. where do we get the revenue? the democratic proposal, the reid bill, decided that they're going to raise taxes on individuals and families and they're going to cut medicare by a half a trillion dollars. what's ironic about that is that a few years ago the republicans, when we were back in the leadership here in the united states senate, tried to do a budget bill that actually achieved some savings in medicare and medicaid to the tune of $27 billion combined. but the medicare savings in that bill were odes 10 billion. that was -- were over $10 billion. $2 billion a year. i want to remind some of my colleagues on the other side about comments they made about that. the senate majority leader at the time -- bear in mind, madam president, this is to reduce medicare by $2 billion per year.

$10 billion over five. the majority leader said, "unfortunately, the republican budget is an immoral document." the senator from west virginia: "this proposed budget coul woula moral disaster of monumental proportion." a couple of my other colleagues in the senate. the senator from michigan. "people who rely on medicare and medicaid are going to be hurt tbhi bill." the senator from wisconsin, "irresponsible and cruel budget. i urge my colleagues to reject this bill." and the former senator from new york, senator clinton, at the time said, "this bill slashes" -- slashes, madam president -- "$6.4 billion of medicare over the next five years." actually it was $10 billion. my point is this: $2 billion a year, $10 billion over five years. these are the statements of --

just the overstatements of the impact of the medicare reductions were going to have on people in this country. we are taking about half a trillion dollar of medicare cuts. where do they come from? $118 billion comes from medicare advantage which now we have about 11 million americans who are impacted by medicare advantage. every state has seniors who have subscribed to the medicare advantage program whose benefits are going to be dput this bill is enacted. you get it out of hospitals. $15 billion in reductions to nursing homes and reimbursements to nursing homes. $40 billion in reductions to home health agencies and $18 gel in reductions to hospices. these are all ways that this $2.5 trillion expansion of the federal government is paid for. i didn't get into the tax cuts which will be a debate for another day. but the medicare cuts in this

bill are unlike anything we've seen past or present. and clearly when you compare it to three, four years ago, we were trying to achieve $10 billion in savings for medicare, you thought the sky was falling. and so here we are trying to pay for a $2.5 trillion expansion of the federal government by cutting $5 billion out of medicare. -- $500 billion out of medicare. the point i want to make because it has been made by the other side this morning -- in fact by the most recent speaker -- that somehow this recent c.b.o. analysis should be hailed as good news. the corks are popping. there's celebration. people are crowing about the new c.b.o. report because it's got such good news for this bill and the impact it will have on people who buy insurance in this company. what is it that they are celebrating? the c.b.o. in its report, madam president, essentially sid this: 90% of americans are going to

see their premiums increase or see virtually the same increases as they do today year after year. that, madam president, is preserving the status quo. , not decreasing costs, as was promised. now, when president obama was running for office in 2007, said when he gets a chance to do health refork, he is going to reduce costs and cover everybody. this bill, after spending $2.5 trillion, and creating 70 new government programs, doesn't cover everybody. there are still 24 million americans who don't get covered under this bill according to the c.b.o. and furthermore, nobody -- nobody -- well, i shouldn't say "nobody." 90% of americans, those who don't get subsidies, don't come out any better. they're still going it see the year-over-year increases in their premiums that they've been seeing over the past several years and the cost of health

care is increasing. you're looking at in the small group market annual increases of over 6% for the cost of health care to the point where a family today that's paying $13,000 a year for health insurance in the year 20169 will pay over -- in the year 2016 will pay over $20,000 for health insurance. if you're in the individual marketplace, your premiums go up. a 10% increase. if you're in the large group market your premiums will go up almost 6%. if you're in the small market, your premiums will go up over 6% per year. we're talking about cutting reimbursements to nursing homes and hospitals and home health agencies and to hospices and raising taxes on health care

providers, medical device manufacturers, prescription drugs, raising the medicare payroll chasm, which incidentally doesn't go to preserve or extend the life span of med care but creates a whole new government entitlement. we are going to do all that for what? at the best, to keep the spha ss quo for people today. at the worst to increase their peoples 10% to 13%. that's bottom line. that's what this is. that's the new c.b.o. report. that's the c.b.o. report that the other side is saying, this is great news. we're celebrating. great news that premiums are going to continue to go up at twice the rate of inflation, just like they have been in the past, protecting and preserving the status quo as we know it in america today. this bill does nothing about the fundamental issue of cost. and it doesn't matter what market you're in. small group market, large group

market stay the same, at best, and the individual marketplace, the premiums go up 10% to 13%. that's the news that's being hailed by the other side as validating the argument for why we need to pass a 2,100-page, $2.5 trillion montana strosty of a health care -- monstrosity of a health care bill. senator mccain has an amendment that would recommit this bill basically to take the medicare cuts out of it. and i hope all my colleagues vote for it, because it doesn't -- they're arguing it doesn't cut medicare. how can you say that? how can you with a straight face say that you're going to find $500 billion to pay for this bill out of med cared and say that it doesn't cut medicare? of course it cuts medicare. of course it raises taxes. you can't finance $2.5 trillion of new spending unless you find

a way to finance it. and the way that testify a chosen to finance it -- and the way that they've chosen to finance it is to hit seniors squarely between the eyes and to cut reimbursements to providers out there across the country who are dealing with the very serious health needs that our senior citizens experience. in my state, we have a lot of people who of course are employed in the health care industry, as i think is true in every state in this country. but even nursings homes -- snawl towns in south dakota -- small towns in south dakota -- you're talking about almost 6,000 employees in nursing homes. $40 billion out of home health agencies, what we're talking about, madam president, are huge reductions in medicare, unlike anything we've seen. as i said to put it in perspective, a few short years ago when we were in the majority in a budget tried to reduce medicare by $10 billion over a

five-year period, it was referred to as immoral, a a monumental disaster, as cruel. $10 billion over five years. this has half a trillion dollars in medicare cuts, medicare advantage and providers. madam president, i hope my colleagues will support the mccain amendment. and i yield the floor. the presiding officer: who yields time? ms. mikulski: madam president? the presiding officer: the senator from maryland. ms. mikulski: i yield three and a half minutes to the junior senator from minnesota, senator franken. the presiding officer: the senator from minnesota. mr. franken: thank you, madam president. i rise to express my support for senator mikulski's amendment for women's health. this amendment is crucial because it's about prevention. prevention is one of the key twhais this bill will -- is one of the key ways that this bill will transform our system of sick care into true health care. it's common sense. you get the right screenings at

the right time so you find diseases earlier. this savings lives and it saves money. the senate bill already has several provisions for preventive care, which i strongly support. for example, colonoscopies and screening for heart disease will be covered at no cost. this is a good start. the current bill relies solely on the u.s. preventive services task force to dermine which services will be covered at no cost. the problem is that several crucial women's health services are omitted. senator mikulski's amendment closes this gap. under her amendment, the health resources and services administration will be able to include other important services at no cost, like the well-woman visit, prenatal care, and family planning. these preventive services will truly improve women's health. for example, if all women got the recommended screening for cervical cancer, we could detect

this disease earlier and prevent four out of every five cases of this invasive cancer. this will improve the health of our mothers, our sisters, and our daughters. this bill and this amendment will make prevention a priority and not an afterthought. although i respect the efforts of my distinguished colleagues -- colleague from alaska, the murkowski alternative false short. the murkowski amendment does nothing to guarantee women will have improved access to coverage and cost-sharing protections for preventive service. rather than establish objectives, scientific standards about which preventive services should be covered, this alternative only requires insurers to consult with medical organizations when making coverage decisions. while we know that the u.s. preventive services task force

recommendation do not cover all necessary services, the murkowski amendment entirely removes even this basic coverage requirement from the bill, leaving women without any protections under health care reform for essential preventive care. this means that important preventive care for women, including screening for osteoporosis and for sexually transmitted infections, may not be covered by insurance plans. in the simplest terms, the murkowski amendment maintains the status quo, and we know the status quo is not working for millions of women who are foregoing preventive care because they simply can't afford it. the murkowski amendment continues to leave prevention coverage decisions up to health insurance companies. and that means there would be no guarantee that any health plan will cover basic preventive services at all. do we really want to leave these

important decisions up to the insurance companies? the health of american women is too important to leave in their hands. that's why i urge my colleagues to support senator mikulski's amendment and vote to make sure women can get the preventive screenings they need to stay healthy. most importantly, this amendment will make sure that women have access to the life -- the presiding officer: the senator's time has expired. mr. franken: may i request another 38 to 45 seconds? the presiding officer: without objection. mr. franken: prevention is one of the ways this bill will improve women's health. it will stop the insurance company practice of charging women more because they happen to be women or denying coverage based on a history of pregnancy, c-sections or domestic violence. we need to pass a bill this year to ensure comprehensive care for women throughout the country and we need to include this amendment because i want to be able to look at my wife in the eye, i want to be able to look

my daughter in the eye. my son too and my future grand tkheurpb in the eye and say that we did everything we could in this bill to improve women's health and we can't wait any longer. and i urge all of my colleagues to stand with us and support this amendment. and i yield the floor. thank you. mr. enzi: i yield to the senator from oklahoma. the presiding officer: the senator from oklahoma. mr. coburn: as a practicing physician who has actually cared for women, which nobody on this floor who participated in this debate has ever done, i congratulate the senator from maryland for her care about prevention, because we all know that's a key. the mischaracterization you just heard about this bill is astounding. the reason we got in trouble with the task force, the preventive task force is because it did something that was inappropriate and didn't have the appropriate professional groups on its task force when it made its recommendation on breast cancer screening.

when the murkowski bill does, says we will rely on the professional societies to make the determinations of what must be available. and we've heard the senator from iowa say health insurance would decide that. that's absolutely untrue. health insurance won't decide it. the professional societies will decide what will be covered, and the insurance must cover it under the murkowski amendment. the second thing is that there won't be any objective criteria. the objective criteria that doctors practice under today is the guidelines of their professional societies. here's the difference between the murkowski amendment and the mikulski amendment. the senator from maryland relies on the government to make the decision on what will be covered. she refers to the health

resources services administration. she refers to the health resources services administration who has no guidelines whatsoever on women's health care right now other than prenatal care and child care. that's the only thing they have. who does hrsa work for? hrsa works for the secretary of health and human services. so the contrast between these two amendments couldn't be any more clear in terms of if you really want to solve the problems that we just experienced on mammogram recommendations. we can let the government decide, which got us into this trouble, and they will set the practice guidelines and the recommendations for screening. or you can let the american college of obstetricians and gynecologists, you can let the american college of surgeons, the american college of oncologists set and use their guidelines. so the choice is real simple. the government can decide what

care you get or the people who do the care, the professionals who know what is needed, who write the peer-reviewed articles, who study the literature and make the recommendations for their guidelines. every month i get from the american college of obstetricians and gynecologists their new guidelines, and i true to follow them at every instance. the fact is the mikulski amendment says government will decide. it's what it says. the government will decide through hrsa. the murkowski amendment says the best practices known by the physicians that are out there practicing, what's the difference? how does it apply to you as a woman? it applies to you as a woman is that the people who know best get to make the recommendations rather than a government

bureaucracy. that's the difference. and if you will recall, under the stimulus bill that we passed, we have a cost comparative effectiveness panel which will surely be mixed into the mix associated with the recommendations. and if you look at what the task force on preventive recommendation said from a cost standpoint, they were absolutely right. from a patient standpoint, they were absolutely wrong. and the real debate on this bill, the mikulski is the start of the real debate, is do we have the government decide based on cost or do we have the professional caregivers who know the field decide based on what's best for that patient. that's the difference. and what the senator from alaska does, which is necessary, is she

says we will rely on the american college of obstetrics and gynecology. we will rely on the american college of surgeons. we will rely on the american college of oncologists to determine what should be the screening recommendations for patients. for you see what happens with the mikulski amendment is the government stands between you and your doctor. that's what's coming that's what will be there. there is no choice under the murkowski amendment for an insurance company to have the option either to or not to. they must. it says "shall do that." so the mischaracterizations on what the murkowski amendment actually says -- the presiding officer: the senator's time has expired. mr. coburn: i would yield the floor. the presiding officer: w yields time? ms. mikulski: madam president? madam president, how much time

does our side have? the presiding officer: 17 minutes and 15 seconds. ms. mikulski: i yield -- the gentlelady from michigan on the floor? i yield five minutes to the gentlelady from michigan. ms. stabenow: madam president? the presiding officer: the senator from michigan. ms. stabenow: thank you, madam president. i first want to thank senator mikulski for her leadership not only on this important amendment, but on so many issues in health care, issues for women across this country. we are honored to call her dean for all of us as it relates to focusing on the issues that are so critical to women and their families. and i want to thank senator reid for making this a priority and

making this the first amendment that we are offering in this debate. we all know, madam president, that often women are the ones making health care decisions for their families as well as themselves. they're more likely to be the person making health insurance choices. and women of child-bearing age pay on average 68% more for their health care than men do. and we have so many instances in which insurance companies are standing between women and their doctors right now in making decisions, decisions not to cover preventative services like a mammogram screening or a cervical cancer screening. decisions to call pregnancy a preexisting condition so that women can't get health insurance. insurance companies making decisions not to cover maternity

care so that women and their babies can get the care that they need so that babies can be successful in life, both prenatal care and postnatal care. so women of this country have a tremendous stake in health care reform. we pay more now if we can find coverage at all. and there are too many ways in which insurance companies block women from getting the basic health services that they need. and so this amendment is critically important to make sure that women are able to get preventative care services without a deductible and without co-pays. we -- this amendment recognizes the unique health needs of women. it requires coverage of women's preventative services developed by women's health experts to meet the unique needs of women. and why do we stress that? we stress that because for years

we have struggled in so many areas to make sure that women's health needs were focused on and not just health in general. when we look at research through the national institutes of health and what it took to get to a place where research would be done for women on women's subjects or on women -- mice and rats, on female rather than male subjects to make sure that the differences between men and women were considered in research. and we've made important steps in that direction. and again, senator mikulski was leading the way as it relates to having a women's health research effort in our country. this is just one more step to make sure that we are covering women's preventative services developed by women's health experts, unique needs of women.

that's what this is all about. making sure women have access to preventative services like cervical cancer screenings, osteoporosis screenings, annual mammograms for women under 50, pwreg nancy and post -- pregnancy and postpartum screenings, domestic violence screenings, annual checkups for women. we know that more women die of health care -- excuse me -- of heart disease than actually any other disease. this is something that i don't think is widely known. we've heard even that many physicians don't realize the extent to which heart disease is prevalent in women. and as all of us have worked -- all the women of the senate have worked together on a women's heart bill, part of that is for screenings. part of that is to make sure that we are screening for heart disease, heart disease and strokes, the number-one killer of women. this would make sure that those screenings would be part of

health care reform. and we could go on to list all of the different prevention items, but i would simply say, madam president, that when we are talking about women's health and we are talking about women's lives, this is an incredibly -- the presiding officer: the senator's time has expired. ms. stabenow: -- thank you. i yield the floor. mr. enzi: madam president, i'd yield five minutes to the senator from texas. the presiding officer: the senator from texas. mrs. hutchison: mr. president? the presiding officer: the senator from texas. mrs. hutchison: madam president, i rise to speak on the mikulski amendment and the murkowski amendment because i feel very passionately about the women's issues. in fact, senator mikulski and i have worked throughout my time in the senate and hers before me on these very issues, assuring that women's health care concerns, which are different from men's in many instances,

are a part of any health care coverage in our country and ongoing we must assure the same. i have been an advocate for cancer screening services for women, and i was dismayed when i saw the united states preventive services task force a few weeks ago issuing new guidelines for cancer screening for women -- breast cancer screening for women. we all know that we have lived with breast cancer throughout, of course, the history of women, but especially in the last probably 25 years the strides that we have made in saving and survivability of women with breast cancer is because we have early detection. we don't have a cure for breast cancer. we're all fighting for that cure. but until we get it, the first line of defense sellerly

detection. so now we have -- but until we get it the first line of defense is early detection. so now we have a task force saying that everything we have had and enjoyed over the last 25 years is no longer relevant because now before the age of 50 you don't really need a mammogram, and after the age of 50, it's every other year. well, i know that senator mikulski and i disagree that we don't think that's right. neither did any other woman in the right when that was proposed years ago by president clinton. we all stood up and said no. and i'm standing up and i'm saying no again, and i'm sure every woman in the senate is, as many women in america are. but the mikulski amendment doesn't actually fully address the problem of having the task force, which is relied on 14 times in the bill before us, as

the arbiter of what is necessary for our government program and then will surely become the private-sector standard as well, and that task force even has money alot allocated to advertis recommendations. so rather than the mikulski amendment severing the advertise with the task force, the amendment now has another government agency that has the same capability to basically interfere between the woman and her doctor, which is where we want the decisions to be made. coverage decisions will be dictated by both the task force and a new health resources and services administration entry into the mix. well, i certainly agree with senator mikulski about the importance of preventive services for women and insurance coverage decisions. i just can't support her

amendment because we still have, not one, but two government task forces and committees that will be in the middle of these health care coverage decisions. i think the coverage decisions should be made by doctors and their patients. that's why i've joined with senator murkowski in offering the alternative approach. this is what we should expect from any future health care reform. it is certainly what we expect today. the murkowski amendment will leave the medical decisions to the guidelines established by those who know medical treatment best, which is our own doctors. in fact, we have just received a c.b.o. assessment of what the murkowski amendment would cost, and it actually says there will be a savings. so rather than the mikulski amendment, which would spend $1 billion over ten years, the

murkowski amendment would actually save $1.4 billion over ten years. why? because the murkowski amendment relies on the combined common sense and clinical judgment o american physicians. the presiding officer: the senator's time has expired. mrs. hutchison: so, madam president, i urge a vote for the murkowski amendment, and i know we have the same goals as senator mikulski and her amendment, but i don't believe the mikulski amendment achieves the goal of having a woman and her doctor make the decisions for her. that's the key that i think is so important in this debate. i urge a vote for the murkowski amendment. thank you, madam president, and i yield the floor. the presiding officer: who yields time? mr. mcconnell: madam president? the presiding officer: the senator from maryland. mr. mcconnellmaryland.mc. ms. mikulski: madam president? the presiding officer: the senator from maryland. ms. mikulski: i yield four minutes to the gentlelady from the state of washington, who has

been a real leader on these issues. by the way, madam president, before the senator speaks, i want to thank senator stabenow for a unique courtesy. this is her desk. and as many of my colleagues know, i broke my desk and i can't get up to where my desk is at this point. i will in a matter of another few weeks. but she's giving me this desk on loan, and i wanted to thank her for the courtesy so that i could stand on my own two feet and debate this. madam president, i also want to note something while the senior senator from the republican leadership is here and the author of the raiment. we, the women of the senate, on a bipartisan basis, have worked for women's health. today we disagree on what is the best way to achieve it by these two amendments. i want to thank my colleagues for setting the tone of civility. i think this has been one of the most rational, civilized conversations we've had on this. and i would like to thank them.

as the leader on this side of the aisle in terms of seniority, i would like to extend my hand in friendship when this bill is done and this amendment is done we continue to focus on this wonderful work that we have done together, and we have. we have done things that have saved millions of lives, and we look forward to it. madam president, i now yield four minutes to the senator from the state of washington, senator murray. mrs. murray: madam president? the presiding officer: the senator from washington. mrs. murray: madam president, i thank my colleague from maryland, and i would just say, wherever she stands on the floor, she leads us all, so we're delighted that you're here and thank you so much for your leadership on this critical issue, making sure that women have access to quality preventive health care services and screenings that are so critical to women across the country. madam president, the senator from maryland offered this amendment, and i worked with her on the committee. she's been a leader on this form, many years.

and i echo -- for many, many years. and i echo her statement. for years the women on this side of the aisle have stood up to make sure that women's care is part of health care and understand that we have to stand shoulder to shoulder. it is unfortunate this time that we see this in a little different light. but i agree with senator mikulski, we will keep working together throughout our time here to make sure that women's preventive services are covered. i do support the mikulski and the mikulski approach. her amendment requires all health plans to cover comprehensive women's preventive care and screenings, at no cost to women. i just wanted to come to the floor for a minute and point out why this is so important. when the economy is hurting, women on the whole tend to think of caring for their families first and not caring for themselves. they take care of their children, their spouses first,

and they end up delaying or skipping their own health care in order to take care of their families. in fact, we know that in 2007, a quarter of women reported delaying or skipping their health care because of cost. in may of 2009, just two years later, a report by the commonwealth foundation found that more than half of women today are delaying or avoiding preventive care because of its cost. that's not good for the women. it's not good for their families. it's not good for their ability to be able to take care of their families and to take care of themselves. so senator mikulski's amendment is extremely important especially in this economic time. we know that if women get preventive care and care for their needs, then they are able to care for their families. yet the situation we find ourselves in today, women are not taking preventive care. they're not taking care of themselves. therefore, when they get sick, end up in the hospital, then

their families are really in trouble. so we know preventive services can save lives and it means better health outcomes for women. we have to make sure that we cover preventive services and it takes into account the unique needs of women. senator mikulski's amendment will make sure that this bill provides coverage for important preventive services for women at no cost. women will have improved access to well-women visits, mammograms that we've all talke talked aboo make sure they maintain their health. i want to emphasize that this amendment preserves the doctor-patient relationship and allows patients to consult with their doctors on what services are best for them. this has become a large topic of conversation over the last several weeks, and senator mikulski's amendment makes sure that it's if a woman under 50 s

to receive a mammogram, this amendment will cover it. so i come to the floor today to strongly support the mikulski amendment to thank her for her leadership on this, and i would hope that we can get to a vote on this important issue and move on and pass health care reform. my constituents when i go home say, move on. get this done. we have got to take care of this because of our economy, because of the impact on small businesses, because of the rising costs of premiums, because of the large number of people who are losing their health care coverage. this health care bill is going to make a major difference when we get it passed, and the american people can take a deep breath and say, finally our government can moved forward. so let's get past this amendment. i support strongly the mikulski amendment. let's move on this bill. let's make a major step forward for health care coverage for all americans and pass the health care bill. thank you, madam president. i yield the floor. mr. enzi: madam president, i'd yield two minutes to the senator from kansas.

the presiding officer: the senator from kansas. mr. brownback: thank you very much, madam president. i rise in support of the senator prosecute alaska's amendment, and i have talked with my good friend, the senator from maryland, senator mikulski, about the issue -- a side issue in this overall debate but what is included in the definition of "preventive care." and the senator from maryland has stated in a colloquy that there are no abortion services included in the mikulski amendment. she has stated that in a colloquy. i have trouble that a future bureaucracy could interpret it differently. i have asked my friend from maryland if she would include clear legislative language in this saying simply that nothing in this act shall be construed to authorize the secretary or any other government or quasi-governmental entity to define or classify abortion or abortion services as preventive care or as a preventive service.

i think that clarifies the issue. it would be my hope that my colleague from maryland would include that in her language. it is not in there, even though there have been statements on the floor. as we all know as legislators, it is one thing to say something on the floorks it is one thing to have a colloquy. it is far different to have a written in the base law enforcement this is not written in the base law. so i would urge the senator from maryland to include this language and absent that i think there's too much room for a broader definition of what "preventive care" means that could include abortion services as well. and i would urge my colleagues to vote against the mikulski amendment if that is the case. on that ground, i think there are other issues that are involved. that's why i think the senator from alaska's approach is superior, while maintaining a doctor-patient privilege. i think this is a good debate for us to have, given these

recent discussions. but absent this change, i think there's another issue that's involved here. and i would urge my colleagues to consider it. i want to yield back to maintain some time for the senator from wyoming to be able to speak. so i'd yield the floor. the presiding officer: who yields time? ms. mikulski: madam president? the presiding officer: the senator from maryland. ms. mikulski: we're waiting for senator boxer to come to the floor, and if the other side of the aisle has another speaker, i know at the end we hope the senator -- at least senator bore be -- becausbarb-- because othed resoundly the same -- the senator could proceed.

we're waiting for boxer or baucus. mr. enzi: i would yield ten minutes to the senator from alaska so that she can actually propose her amendment that we've been debating and take up to 10 minutes. ms. mikulski: then i'll wrap up. is that -- mr. enzi: that would still leave us with two minutes. if it does leave us with two minutes, then i would have the senator from wyoming use that two minutes. ms. mikulski: whatever way we could work and accommodate while we're lining up our speakers. a senator: mr. president? the presiding officer: the senator from alaska. ms. murkowski: mr. president, i want to start my comments by acknowledging my colleague from maryland and accept her gracious offer to continue to work on this issue as it relates to women's health and women's health services. as has been noted by the senator from maryland and the senator from washington, this is an issue that we women of the

senate have come together repeatedly to work cooperative cooperatively, and while we do have some would say dueling amendments here, i think it is important to recognize that the goals that we are both seeking to attain here are certainly right in alignment. we're just choosing different means to get there. but i appreciate again the civility and the cooperation from not only senator mikulski but the other women of the senate on this very important issue. mr. president, i'd like to reiterate a couple points about the amendment -- my amendment that i made yesterday. the presiding officer: the senator from maryland. ms. mikulski: mr. president, i fear that the gentlelady from alaska's microphone is not working. ms. murkowski: let me try it here. ms. mikulski: that's so much better. i want to hear the amendment and continue our conversation. ms. murkowski: and you just

missed all the kind remarks that i addressed to your attention. ms. mikulski: could i ask unanimous consent that she be extended for two additional minutes. no, no, i draw. thank you. ms. murkowski: i'll make sure that the comments that were made in the record are delivered to you personally, senator mikulski. but i want to reiterate a couple of points i made yesterday about my amendment and to also share with my colleagues, and i know that the senator from texas mentioned it as well, the c.b.o. score that we received yesterday -- actually late last evening. it provides us with a score showing a cost savings of $1.4 billion over the next ten years. and i think that this is significant, as members certainly from the other side have raised the importance of fiscal discipline and -- and our financial -- fiduciary responsibility here. i think importantly, the c.b.o. indicated that the provisions on the second page which prevent the secretary from using the recommendations of the uspstf to deny care would cost money, which means that we are, in

fact, protecting certain benefits and that is very important. the amendment that we have before us, the murkowski amendment, is one that really allows for or requires a level of transparency with the recommended health screenings, the prevention services that are deemed necessary not by some task force that is appointed by folks within the administration, not by some commission that has political relationships. what we are urging is that the screenings, the health screenings, the preventive services, that these be determined by those who are actually in the field. those practitioners, those who are engaged in -- in oncology, ob-gyn's.

we need to be looking to the experts. we need to be looking to that peer-reviewed science. we don't need to be looking to those entities that have been brought together by a government entity or by the secretary. we need to be looking to the likes of the american society of clinical oncology, the american college of surgeons, the american college of radiation oncology, the american college of obstetricians and gynecologists. we need to look to their recommendations. and, again, as i mentioned yesterday in my comments, if you go to their web sites, if you look to their specific recommendations, they will give guidance, guidance that, again, is based on their practice in oncology, their practice as an ob-gyn. look to what they set out as the guidelines for cervical cancer screening, for -- for mammograms

and -- and let that information be made available, made available publicly through -- through the pamphlets, the -- the plans that come together from the insurance companies. but allow them -- allow me as a -- as a consumer of health care, me as a consumer looking for the best plan for me and my family, to know what those guidelines are, not from a government task force but from those that are the -- the -- the real experts. i think this is the transparency that health care shoppers are looking for. now, some have suggested that, well, lisa, your amendment doesn't require the insurance companies to provide any prevention or screening services, there's no mandate in there. and that if we don't have a mandate, then the insurance

companies aren't going to provide health care prevention, screening and services. i think we need to ask the question here: what is the point of prevention? if it's to prevent more expensive care in the future by preventing the chronic and the more acute illnesses. so shouldn't the insurance companies want to utilize more preventive services, utilize more screenings, more wellness services in order to keep down the costs of care based on the judgment of the doctors, based on the judgment of the professionals and not necessarily those that, again, are -- are appointed as part of the government entity? i know that within my staff, i have a staff member who -- she's on the fehbp plan, but they contact her on a somewhat regular basis about her diabetes care, ensuring that she's taking her medications, getting the necessary preventive services offered by her insurance for her particular condition. it's been -- it's been mentioned by several of my colleagues

that, well, this uspstf, they're not such a bad group of guys, they are not just these -- these nameless, faceless bureaucrats. i think it is important to recognize, and even the american heart association has recogniz recognized, that the preventive services task force is limited to only primary care doctors and not specialists, like the oncologists, the cancer doctors who see patients every day who are battling cancer. so, you know, shouldn't the doctors that are providing americans with their suggestions on what services are necessary for cancer screenings but yet these doctors are not part of this task force that has -- has really, again, shown the -- shone the spotlight on what happens when you have a government entity or a government task force that is basically the one that is saying this is what's going to be cofd, this is not what -- covered, this is not what -- what is not going to be covered. in my amendment, we specifically provide that the -- the recommendations from uspstf

cannot be used to deny coverage of an item or a service by a group health plan or health insurance offeror. i think that's very important. i think it's also important to recognize that what we do in my amendment is to make sure that the health plans consult the recommendations and guidelines of the professional medical organizations to determine what prevention benefits should be covered by all these health insurance plans throughout the country. we also require plans to provide this information directly to the individuals. you get to see it for yourself. you get to make that determination. and so what that means is that it's not the doctors and the specialists -- it means that -- it does mean that the doctors and the specialists will be recommending what preventive services to cover, not -- not those in washington, d.c. my amendment ensures that the secretary of the health and human services shall not use any of the recommendations, again, made by the task force to deny

coverage. we also include broad protections to prevent bureaucrats at the department of health and human services from denying care to patients based on the use of comparative effectiveness research. and then finally, we have a provision that ensures that the secretary of health and human services may not define or classify abortion or abortion services as preventive care or as preventive services. the presiding officer: time has expired. ms. murkowskims. murkowski: i ae that, mr. president. i think the amendment is straightforward. i think it's a good compromise. and, again, i think it is a clear differential between what we are trying to do to allow a woman to have full choice with her doctor as opposed to -- to government telling us who should -- who we should be seeing. and with that, mr. president, i yield the floor. the presiding officer: the senator from -- ms. murkowski: i want to ask consent to call up my amendment number 2836.

the presiding officer: the clerk will report the amendment. the clerk: the senator from alaska, ms. murkowski, for herself and others, proposes an amendment numbered 2836 to amendment number 2786. ms. murkowski: i ask that further reading of the amendment be dispensed with. the presiding officer: without objection. mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: mr. president, i have ten unanimous consent requests for committees to meet during today's session of the senate. and they have the approval of the majority and the minority leaders. and i ask consent that these requests be agreed to and that these requests be printed in the record. the presiding officer: without objection. mr. baucus: mr. president, just -- i'm just going to speak very, very briefly on the pending subject and then let the sponsor of the amendment, that is, the mikulski amendment, finish up here. i think it's very. i know this point has been made before but i think it bears repeating. the american heart association, the american stroke association

has a written -- released to the senate and i'll just read the -- the most important parts here. basically they say they strongly support health plans to provide first coverage for clinical preventive services that are evidence based and necessary for the prevention or early detection of an illness or disability. we all agree with that. they go on then to comment on the murkowski amendment, saying that they appreciate the murkowski amendment recognizing the value of the guidelines and recommendations but they go on to say that even these guidelines must be held to a standard of being evidence bas based. i might say that this is -- i run across this over and over and over again in the medical profession and medical experts, that we just need to keep moving more and more and more toward evidence-based medicine. this statement from the american heart association, the american stroke association goes to say, "in addition, we are concerned

that senator murkowski's preventive health services amendment would take a step backwards by substituting the judgment of the independent u.s. preventive services task force with the judgment of private health insurance companies." that's a frank -- frankly, that's a point i very much agree with. i don't think we want the judgment of private health insurance companies making these decisions. and i'd like now to -- to defer -- to recognize -- i don't need to recognize, i just think it's appropriate the sponsor of the main amendment finish up. she's doing a very good job. a senator: mr. president, i'd yield our final minute to the senator from wyoming. the presiding officer: without objection. mr. barrasso: mr. president? the presiding officer: the senator from wyoming. mr. barrasso: thank you, mr. president. mr. president, my wife, bobbie, was diagnosed with breast cancer by a screening mammogram in her 40's. it's that screening mammogram that has saved her life. by the time of the mammogram, the tumor had spread and she's

had three operations, two full bouts of chemotherapy. i do not want a government bureaucrat making a decision for the women of america if they should be allowed to have screening mammograms. it saves lives, 1 in 1,900 for women in their 40's. the reid bill empowers bureaucrats to decide what benefits will be allowed for the american women. the amendment from the senator from maryland does the same: bureaucrats, not the physicians who are in the -- who are doing the treating. and that's why i support the amendment from the senator from alaska, because that amendment says the federal government cannot use recommendations of the u.s. preventive services task force, recommendations from bureaucrats to deny care to anyone, including seniors on medicare, anyone in america. that's how decisions should be made, not by government bureaucrats. thank you, mr. president. i yield the floor.

ms. mikulski: mr. president? the presiding officer: the senator from maryland. ms. mikulski: mr. president, how much time is left on our side? the presiding officer: 3 minutes. ms. mikulski: mr. president, i yield myself three minutes. as we get ready to conclude the debate on both the mikulski, as in barbara mikulski, and murkowski, as in lisa murkowski, amendment, i want to first say a word about the senator from alaska, that we've worked together on the health, education committee, we've worked together on the -- as women of the senate to provide access to women's health services, and not too long ago when i had my awful fall, she gave me much wisdom and counsel and practical tips because she herself had broken her ankle. so to us, when you say to senator lisa or to senator barb, "break a leg," it has a whole different meaning to us.

and i again want to thank her for all of her work, and i have great respect for her. and look forward to our continued working together. but i do sincerely disagree with her amendment, because what her amendment does is it guarantees really only information. it does not guarantee universal access to preventive and screening services. and it also does not remove the cost barriers by eliminating the high deductibles or the copayments when you go to get a preventive or screening service. it tells insurance companies tot recommendation on recommended preventive care, that's a good thing. it's a threshold thing. you need universal access to the service. also, we do not mandate that you have the service. we mandate that you have access to the service.

the decision to whether you should get it will be a private one unique to you. we leave it to personalized medicine. so in the poignant case that we heard about the senator from wyoming's wife, that would have been up to the doctor and the physician to get her the service that we need. the -- and it's not only i or one side of the aisle that's opposing the murkowski amendment. the american cancer society does, it the american heart association does it, the american academy of gyn services does it. i think my amendment is a superior amendment because it guarantees universal access to preventive and screening services. it also eliminates one of the major barriers to accessing care by getting rid of high payments an deductibles. what does it mean? it doesn't say you will have a mammogram at 40. because, again, we're

substituting ourselves with the task force. you will have universal access to mammogram if you and your doctor decide it's medley necessary or -- medically necessary or medically appropriate. i say vote for mikulski. don't vote for murkowski. and, please, on this one get it straight. the presiding officer: under the previous order the question is on amendment number 2791 offered by the senator from maryland, senator mikulski, as amended. ms. mikulski: i ask for the yeas and nays. the presiding officer: is there a sufficient second? there appears to be. the yeas and nays are ordered. and the clerk will call the roll. vote: