and i don't see how anybody could argue that this doesn't save tax dollars. well, in fact, there are statistics that prove that statement. according to the national association of home health care and hospice, an average per-visit medicare charge for home health is $132. let me compare that charge of $132 to one day at a hospital that would cost 43 times as much, literally. $5,0766 per day. according to to a study, and i'm quoting, early use of home health care services following a hospital stay by patients with at least one chronic disease saved medicare $1.71 billion in

the two-year period of 2005 to 2006. unquote. saved medicare. doesn't it seem like an enormous step backwards when we talk about reform, when really what we're doing is cutting a program that serves people so much in need and yet saves money in our medicare program. home health agencies in nebraska have been very successful in doing exactly what we want, keeping people at home and out of the hospital and nursing home. of special interest are patients with congestive heart failure. one nebraska woman turned to home health after facing a big stack of hospital bills for rehab. since then, she has been able to remain at home safely at a fraction of the cost. this home health agency can see a person for 60 days at a cost

of about $2,500. 60 days. one hospital admission, by comparison, would cost medicare conservatively $20,000 to treat a patient with chronic health failure -- or chronic heart failure. so, again, home health care costs a fraction of hospital care, about ten times less. there are so many stories from patients who are alive today who love home health care. and this bill threatens them. somewhere in the next hours, mr. president, i'm going to send to every member of the united states senate all of my colleagues, a state-by-state analysis of what these cuts will do in their state, because they need to know the impact. this bill threatens to take that all away. you can't cut $42 billion and just describe it as excess

payments. you can't cut $42 billion and say, well, that's just fixing those who are bilking the system. when you cut $42 billion out of a program like home health care, it has real consequences. earlier this week, mr. president, i did a video conference with medicare providers in nebraska. these nebraska home health providers reported this legislation will cost them $120 million in my state. what does that mean? $120 million may not sound much around here where we talk about trillion-dollar programs. $120 million to the people of nebraska in home health care, 68% of home health agencies in nebraska will be in the red by

2016. 68%. in rural areas, as high as 80% will have negative margins. you lose those services in rural areas, they are lost. there's nothing that will step in for those people. home health providers already have to watch their bottom line, and they're already making very hard, painful decisions. during this video conference, a nurse in rural nebraska explained the reality to me this way -- and i'm quoting -- "i can give you a human story that just happened yesterday in our agency. we had a referral from a patient that lives 90 miles away. the drive time is three hours. to do the admission takes one and a half to two hours. and then you come back to the office, and you do at least

another hour of paperwork. it would take one person's entire day to serve one patient. and regretfully, we had to say no. we just could not see her. and there is no other agency close enough to help this woman." unquote. can you imagine, mr. president? we have a person who desperately needed these services, and we're debating whether we should cut $42 billion out of this program, impact a state like mine to the tune of $120 million? these agencies and the services they provide absolutely are reliant on medicare. according to the national association of home care and hospice -- and again i'm quoting -- "medicare is the largest single-payer of home health care services." unquote. when we cut the payments in a program like this, we cut access to care.

these access concerns are rooted in real-life experiences. between 1998 and 2000, medicare home health spending fell from $14 billion to $9.2 billion, or negative 34% as a result of congressional action between 1998 and 2000. those actions triggered the closure of 40% of home health agencies and reap dued access for -- reduced access for 1.5 million medicare beneficiaries. access becomes a real issue. if there's no home health agency, homebound patients end up with more expensive care in hospitals and nursing homes, and that costs medicare money. but, you see, we're also cutting hospitals and nursing homes in this bill. if there is no home health

provider near the area, not only are medicare beneficiaries hurt, but all citizens who need the care. you know, mr. president, any analysis is going to come to the same conclusion. and i'll quote from one. quote -- "studies from medpac and the government accountability office also suggest that access is a growing problem for patients who require intensive services. in june 2003, medpac issued a report indicating that skilled nursing facilities care is now substituting for home health care for some patients. most likely at a much higher cost for medicare." unquote. well, i don't think these are transformational reform. these cuts are not transformational reform. they're just plain cuts to start

a new entitlement that hurt real people: senior citizens who need our help. that's why i'm offering this amendment to recommit this legislation back to the finance committee, to strike these ill-advised home health care cuts from it. mr. president, i will follow up. i will make sure that every member sees the impact of these cuts in their state so they can make an assessment. should these cuts be put in place and cause the kind of damage that i've described this afternoon? thank you, mr. president. i yield the floor. the presiding officer: the senator from maine. mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: i yield to senator klobuchar ten minutes. ms. klobuchar: thank you very much. the presiding officer: the senator from minnesota.

ms. klobuchar: i ask unanimous consent to peek for up to 12 minutes. the presiding officer: without objection. ms. klobuchar: i rise today to speak about true health care reform. the way i look at this in my state is it's a matter of affordability and cost. we have one of the highest percentage of people covered in the country, mr. president, in minnesota. but the issue is it's becoming more and more expensive for the people of our state to afford health care. i try to remember three simple numbers of all the numbers we're going to hear in the next few weeks. those are the numbers 6, 12 and 24. ten years of cola costs $6,000 for an average family to pay for their health care a family. now it's $12,000 with a lot of people paying a lot more. ten years from now if we don't do anything, it's going to be somewhere between $24,000 and $36,000 a year, something regular people just can't afford. 6, 12 and 24. it's not going in the right direction, mr. president. if we don't act, costs will continue to skyrocket. the country spent $2.4 trillion

on health care last year alone. that's one out of every $6 spent in the economy. by 2018 national health care spending is expected to reach $4.4 trillion, over 20% of our entire economy. despite spending one and a half times more per person on health care than any other country, many of our people don't even have health care coverage. and many of them are losing their coverage because of preexisting conditions or because it simply is costing too much. these costs are breaking the backs of our families and our businesses. you can see here, single coverage, 1999, $2,192. in 2008, the last figures we have available, $4,704. a doubling. family costs $19 -- 1999 tkhr-rbs 5,791. now what are they paying?

$12,680. now look what's happening to small business, mr. president. a study by the council of economic advisors found small businesses pay up to 18% more than large businesses to provide health care coverage. in a recent national survey nearly three-quarters of small businesses that did not offer benefits cited high premiums as the reason. now look at it this way, mr. president, inflation usually raises the cost of most goods and services between 2% to 3% per year. health care premium costs already have been going up close to 8% a year. that's an increase americans just can't afford. wages have not kept pace with an increase in premiums. wages. look at this. between 1999 and 2007, the average american worker saw his wages increase 29%. obviously the last few years it has not been that rosy. but 29% between 1999-2007.

how much did his insurance premiums go up? 120% during the same time period. so, in other words, these health care premiums are taking on a bigger and bigger chunk of the average worker's paycheck. and these costs are breaking the backs of the american taxpayer. my colleague across the aisle was talking about medicare. well, the truth is this, medicare is projected to go into deficit by 2017 if we don't do anything about it. and recent congressional budget office estimates show that the majority of the projected $344 billion increase in federal revenues are scheduled to automatically go to cover rising health care costs. medicare, something that people who are 55 want to get when they're 65. people who are 65 want to keep their medicare until they live to the ripe old age of 95. but if we don't do anything about it, it's going in the red by 2017.

how do we do this? how do we get to the place we want to go? we must get our money's worth from our health care dollars. the problem now is we're paying too much and we're not getting a good return on what we pay. the solution must be to get the best value for our health care dollars. otherwise, costs are going to continue to wreak massive srobg on the budgets of -- to wreak havoc on governments, business and individual families. health care is 57% of all federal health spending. if we want to sustain medicare, which we all do, to provide that kind of high-quality health care that our seniors deserve, we must do something to address the fiscal challenges. the root of the problem is that most health care is purchased on a fee-for-service basis so more tests, more surgery means more money. quantity, not quality pays. according to researchers at darthmouth medical school nearly $700 billion per year is wasted on unnecessary, ineffective care. now, my favorite example with

all this is what a clinic did in pennsylvania. they weren't happy with how their diabetes treatment was going. they said we're going to have our routine patients see nurses. and more difficult cases will see doctors. then those epidemiologists will review the records of the nurses and make sure that the patient is progressing as we want. guess what? patient quality goes way up because they see nurses and they see them more regularly. results go way up because the epidemiologists are spending their time on the most difficult cases and reviewing the records of the other. costs go down $200 per patient per month. guess what? they get paid less, way, less for that kind of quality care. that's why the system is messed up and we need to change it. we are rewarding based on results. we put the patient in the drivers seat so when that patient gets better results, we reward with payments. in minnesota, we have several great examples of this coordinated outcome system.

at a place like the mayo clinic, park nick let, st. mary's in duluth, it is value, not volume. everywhere in the country mirrored the efficient level of spending in the mayo's clinic home region in minnesota. for the last four years of chronically ill patients' lives if we used that same system all over the country, if we used this system in texas, florida, we would spend -- save $50 billion every five years and get higher quality care. this is not like a hotel where you pay more money and get a better care. in this system when you pay more money you get less quality care. that is where we need to bring the country, efficient care that costs less but is better value. that's what we

need to do. linking rewards to the ou outcos creates an incentive for physicians and hospitals to work together to improve quality and efficiency. using bundling to bill for bundling so you look at the whole outcome of everyone working together, so you rely on nurses when you want to rely on nurses, you rely on doctors when you want to rely on doctors. reducing hospital readmissions -- you wants to go back in the hospitalhospitals there are a lf infections. when the go back into the hospital, the hospital gets rewarded for that. so we want to put in place protocols that make hospitals safer places to get treats. one-year hospital readmissions cost medicare $17.4 billion and in 2007 report by medpac found that medicare paid an average of $7,200 per readmission that was preventable. integrated care -- where you've got a quarterback that's the primary care provider working with a team. instead of having 15 specialists

running around the field running over each other, you have a quarterback. well, let's just say like brett phaser of the minnesota vikings. you have one quarterback who is your primary care doctor who is in charge with a team of doctors who look at all the records. that's integrated care. that's what this bill does. you think about the money we can save. medicare fraud alone coste costs taxpayers more than $60 billion a year. the money is going to conmen, people leaching off the system, people making up that they are providing services when they're not. we have a bill w we're working together to bring that down so that money can go to our seniors instead of going to a burchl of people who are ripping off the system. you look at how you save money, you look at how you reduce covelets in medicare. well, you reduce costs in medicare by making changes to the system and making this work.

we must look to the future, mr. president. that's why health care reform this year is so crucial. this bill is not about today or even next year; it's about five years, it's about ten years from now and beyond. we can't afford for the people of this country to hold off any longer. we can bring these costs down. we can bring the quality up. and we can reward the people of this country for the money that they're putting into health care. thank you, mr. president. and i yield the floor. we have one correction to the record, which i will smivment. a senator: mr. president? the presiding officer: the senator from south contrarily. mr. demint: thank you, mr. president. i appreciate the comments from the senator from minnesota. it brought out a lot of important issues as far as the rising cost of health insurance, and i certainly knew that, as a small businessman. there's only one problem. the bill that we're going to vote on doesn't solve those

problems. in fact, c.b.o. basically tells us that insurance will continue to increase at the same rate it is now and for those with individual insurance policies, it's very likely to go up. mr. president, we're here on friday evening being told we're going to work through the weekend, maybe next weekend, all the way up to christmas eve, with the intent to rush through a bill that many have called -- and i agree -- one of the worst pieces of legislation and one of the biggest threats to health care that we've ever seen here in this country. and apparently the majority wants to rush this through and hopefully i think intimidate the minority into allowing it to go through by keeping us here on weekends over the holidays. but i'm proud that republicans are standing together against this bill and standing with the

american people to stop the democrat government takeover of health care in america and to stop them from paying for it by cutting nearly $500 billion from medicare and raising taxes on millions of americans. i heard from one of our constituents that was talking about medicare and the cuts in medicare explaining very simply that medicare is something he had paid for his entire 40 years of working out of his payroll taxes, and now he could not believe that we were considering taking any money out of medicare in order to pay for a new government program. americans work and pay for medicare so that when they retire, they will have benefits that gives them the coverage they need. i think the majority must think americans are not paying attention or maybe even they're not real smart, that you can

take $500 billion out of a program that's already bankrupt and expect the benefits to stay the same when already we know we're not paying doctors enough to see our seniors and more and more physicians are not even willing to see medicare patients. if there really is waste and fraud in medicare -- and we know there's some -- we should find it and put that money back into the medicare system so that we can keep our promises to seniors. every democrat here in the senate has already voted for a government takeover of health care, to cut medicare to pay for it, and to raise taxes. some of them said they were just moving the debate forward. but i ask you, what debate? will there be any serious consideration to take this government-run plan out of this bill? there won't be. we've already seen that there's no serious consideration to stop taking money out of medicare to

pay for it. in fact, we've had a lot of debate about what this is going to do, to cut from medicare, what it's eventually going to do to benefits, cut medicare advantage. now we're talking about cutting home health, which is so important, particularly in rural communities and for the more elderly constituents that we serve. there's no way you could take this money out of medicare without hurting the programs. instead, as we look ahead at more people retiring than ever in history and medicare being bankrupt, we need to be looking at ways that we can shore up in program so that it will be there for generations to come. every republican voted "no." every republican in this senate has stood with the american people and stayed "no" to a health care bill that takes over the most personal and private part of our lives. i'm proud of our party, and our

leadership. and americans have been asking to see the differences between the republican and the democrat party, and i think now more than ever on this issue they're going to see the democrats standing with government-controlled health care, cuts in medicare, increased taxes, and on the other side republicans who are going to stay here through christmas or new year's or whatever it takes to stop this bill and to sit down and really reform the system in a way that will lower cost and improve care to all americans. we need to continue to talk about these bigger issues, particularly how it affects medicare. and we'll be doing that over the weekend. but i think we owe it to the american people to begin to open this bill up and explain what's in it. i can almost guarantee you that there's not one member of the senate who's read it yet. we're going to try to fit this in santa's slay thi santa's sleo

it'll be delivered to ever american. i've got the first part here. 1,000 pages, small print, front and back. started going through it putting tabs on different pages so we can talk about the different things because sometimes they sound so extraordinarily people don't really believe they're in there. i'm not sure we'll ever get through the whole thing, but i just wanted to take a couple parts tonight and just start talking about what is really in this bill. on page 17 in section 2713, it is intieltded "coverage of preventive health sfertions" which is really our jargon for rationing if says a group health plan and health insurance issuer offering group or individual health insurance coverageern provide coverage fror evidence-based items or services that have in effect an "a" or

"b" rating in the current recommendations of the united states preventive services task force. and we heard from this task force a few weeks ago. but this may sound harmless enough, as you look at it. but let's see what this really means. evidence-based. "a" or "b" what's not "a" or "b"? well, we just found out something that was not "a" or "b." mammograms are a "c" rating and the task force came out and said it should not be covered on anyone under 50 years old. now, that's in the bill that it would not cover mammograms for folks under 50 years old. because it's not "a" or "b" because of the outcry, we had an amendment from the other side to give themselves a little bit of cover on that one medical procedure, mammograms. and we passed it with some fanfare yesterday, but the fact

is, there are going to be many "c" ratings that aren't covered. what are we going to do here in congress over the next several years when we find constituents are not covered for things that they need in retirement from medicare? are we going to pass bills to try cover those individual things? what we should really do is throw out the bill that's causing the problem. we should not be rationing care to our seniors. let's look at another page. and i know this is not as interesting as talking about theoretical stuff. but on page 33, section 2719 called "the aappeals process," a group health plan and a health issuance issuer offering group or individual health insurance coverage shall implement an effective appeals process to provide notice to enrollees in a

culturally and linguistically appropriate manner." now, what do we think that mea means? well, in fact in 2001, this term has been used before in the department of health and human services spent $10 million to figure out what that phrase meant -- means. and we still don't know. i mean, it says "health services that are respectful and responsive to cultural and linguistic needs." but what it really means to us in the 2000 census is there are at least 20 languages spoken by at least 200,000 americans in this country, and what we're putting out there is a liability for every insurance company who doesn't have every aspect of their plan in those 20 languages. it may sound like a simple thing, but every page of this bill almost as you read it, you realize it's increasing complexity and cost of the system here in america.

i'll just cover one of -- one more of these, as i hear my colleagues urging me to finish here in the background. but i do think we owe it to the american people to grin to talk about -- to begin to talk about what's really in this bill. on page 39, it says under "funding category" -- "out of all funds in the treasury not otherwise appropriated, they're appropriate to the secretary $250 million to be available for expenditures for grants under paragraph 1 and subparagraph 1." and what those subparagraphs are are to track the trends in premium increases of health insurance once this bill goes into effect. $250 million to do what the congressional budget office has already told us is going to be increases. but this kind of spending and this type of bureaucracy and complexity that we're creating is not going to make health care

more accessible and more affordable for americans. it is creating a complex bureaucracy with tens of thousands of workers and bureaucrats to tell us what to do -- tell doctors what to do and hospitals what to do and for us how to manage our health care. the congressional budget office has already release add report finding that the purchasing health insurance exchanges that are in this bill could pay up to 16% more for health care than we do today. yet we're moving ahead with this bill. i'll continue throughout this weekend and every time i get a chance to speak to talk about more of these things that are in this bill. folks, this is not a bill we should deliver to the american people for christmas this year. this is a bill that we should throw out so that we can start over and have a step-by-step approach to make health insurance more affordable and available to every american. with that, mr. president, i yield back.

a senator: mr. president? a senator: mr. president, i think we're going bac back and h here. a senator: there's no forth. mr. baucus: sorry? a senator: there's no forth. we can go back and back and then forth and forth. mr. baucus: forth and forth and to and fro, and this and that. that's fine with me. a senator: mr. chairman, time's wasting. i only have seven minutes. a senator: madam president? the presiding officer: the senator from delaware's

recognized. mr. kaufman: mr. president, i ask to speak in morning business for up to five minutes. the presiding officer: without objection, so ordered. mr. kaufman: madam president, i rise to honor the service of a great federal employee. human ingenuity is boundless. this is especially true in america, which has always been driven by an entrepreneurial spirit and belief that nothing is ip possible. -- impossible. from the electric telegraph to the refridge rated railcar, our forebearers helped to build a nation. such invention closed the western frontier in the 19th century. in the century that followed americans continued to be pioneers on that frontier which has no end, the frontier of spbs. -- science. 67 years ago this week, a team of physicalists led by fredericko ferni, they huddled

under the stands of a football stadium in the university of chicago, they initiated the first ever controlled nuclear reaction. that experiment called the chicago pile one, marked the beginning of the nuclear age. madam president, today all americans know that the discovery of nuclear power was a mixed blessing. with it came the potential for a new form of energy to power our homes an businesses. for the first time our naval ships could remain at sea and on guard for extended periods without refueling. with the nuclear energy came nuclear weapons, this led to the mass destruction of hundreds of cities within weekends. they brought us the generation of duck and cover and back yard fallout shelters. thankfully, though our nation and others continue to possess these weapons in our time, the cold war is over. no longer are we minutes from

destruction the way we once were. today peaceful nuclear energy provides one-fifth of our nuclear energy and there are 104 nuclear reactors across the country. developing and enforcing the regulation that's keep these reactors safe are the men and women of the united states nuclear regulatory commission. i want to recognize the contribution of dr. garrith perry. he has a distinguished career at the nuclear regulatory commission. he is also a 2004 recipient of the distinguished arthur s. fleming award for public service. he immigrated to this country from the united kingdom has 30 years of experience for developing models for problemistic risk analysis or

n.p.r.a. -- with the office of nuclear reactor regulation, he was one of the leading experts on analyzing common cause failure and human reliability. his work led to the development of p.r.i. standards and the use of p.r.a. to perform risk informed making with regard to nuclear safety. garreth worked hard to ensure the safety of americans, civilian nuclear fits. the kind of work he performed is highly mathematical and complex. and it may not sound glamorous to the average american, but it is critical and continues enormously to the security and economic well-being of our nation. 67 years ago, there was the power of the atom. today men and women of the nuclear regulatory commission that our modern nuclear reactors continue to do so safely. i hope my colleagues will join

me in honoring the service of dr. garreth perry and all who have worked and continue to work at the nuclear regulatory commission. i yield the floor. a senator: madam president? the presiding officer: the senator from kansas is recognized. a senator: i truly appreciate it, madam president. mr. roberts: i rise today in support of my good friend from nebraska, my colleague from nebraska, senator johanns. with his motion to the official words to commit the bill back to the senate finance committee with the instructions to cut the home health care benefits. what the distinguished senator is trying to bring commonsense cuts to bring care to not only rural areas, but all over the

country. the bill that we're considering would cut home health -- the bill sometimes called the behind the closed door bill. it would cut health care $32 billion. now the senator from nebraska said that's a head scratcher. and that certainly is. it is more than a head scratcher, it is a lizzie borden amputation in regards to a vital, vital program. home health care is certified -- pardon me -- is critical for our seniors, obviously that's the true and as co- chair of the rural health care caucus, i certainly understand that. so does the senator from nebraska. he was saying yesterday how many times he visits his rural hospitals, rural clinics, rural hospices, and you do that a lot if you're from nebraska, iowa, or texas or kansas. and so at any rate in my home state of kansas and in other rural areas, many seniors live alone out in the country, miles

away from a local hospital or doctor's office and even if they have a very good doctor, they couldn't get there from here because of their health care condition. so home health care allows that senior the freedom and independence, mr. president, to stay in their home and the comfort of knowing somebody is there assisting their health care needs. more importantly home health care is -- is the cost effective care, as the senator from nebraska has pointed out, that keeps the senior out of a nursing home or hospital. and question guess what? saves the government money. over the long term of health care, you will increase the cost in regards to nursing homes. no question about it. in my state i've had the pleasure being able to see firsthand, just like the senator from nebraska, the great work that our home health care association does every day.

i was invited into the home of a lovely couple in concordegentleman, and despite having multiple health issues duane and phyllis were able to stay in their home with their little dog josey thank to a home health care aide and a nurse. what's going to happen to seniors like duane and phyllis if we slash $32 billion from home health care participates? it is one of the largest cuts in the whole bill next to medicare advantage. the senator from nebraska had that chart with all of the cuts to all of the providers. don't forget this comes on the heels of several years of additional cuts to home health care. around the $35 billion all told that already have a large percentage of kansas home health care agencies operating at very slim or negative medicare

margins. i know the same is in iowa. i know the same is in monday. the same is in texas. the same is in nebraska. all over the country. i keep hearing my colleagues, however, on the other side of the aisle insisting that they're half trillion dollar cut to all medicare -- here's the quote -- "won't affect the benefits guaranteed to seniors." please stop that. that is the most disingenuous smoke screen in this whole debate. it may be true. it may be true that this bill does not explicitly cut benefits. my friends, however, across the aisle cannot deny that their cuts in reimbursement to providers will affect those benefits. because when you cut the reimbursements to providers, guess who pace the price? the patient. david. or pardon me and duane and

phyllis and their dog josie. you come to their house and make that argument that if you close down or make cuts to home health care, duane's not going to like it, phyllis' not going to like it and josie will bite you on your leg. many of my kansas home health care agencies are working at negative margins. the cuts as provided by the distinguished senator from nebraska, $240 million. the gentleman from montana, the distinguished chairman of the -- of the finance committee, my dear friend, that's $60 million in montana, in nevada, where the distinguished majority leader lives, the chart that's just been provided to me by the senator, $263 million. texas -- texas we have senator cornyn sitting right behind me here. senator cornyn, you're in th

the $6.8 billion category. what will happen if you get cu cut $6.8 billion in regards to home health care, sir? mr. cornyn: if the senator will yield for a response. $6.8 billion will cut not just into the muscle, but into the bone and deny a lot of people -- a lot of elderly people, particularly in rural areas, access to care entirely. mr. roberts: i thank the senator. the senator from nebraska has already pointed out what happens in nebraska. and i know what will happen in kansas. nearly two-thirds of kansas home health care agencies will have negative margins one five years, probably two or three, if these cuts are allowed to occur. mr. president, how are these agencies supposed to stay in business with these kinds of cuts? the home health care benefit will be worthless to a kansas medicare patient whose home health care agencies will go out of business. so, yes, in fact, this bill will

effectively cut benefits. again, get rid of the smoke screen. and this just doesn't apply to the home health care benefit. the same can be said for the effects of the cuts as demonstrated by the senator from nebraska, to reimbursement for hospitals. $1.5 billion, this bill is going to cost the kansas hospital association. because some outside experts came in. i asked them what will be the effect of the cuts. they already have cuts. they only get reimbursed 70% now, and $1.5 billion on top of that. we ought to have a chart, i'm sure that we will have a chart to say to iowa, nebraska or any state here, and texas especially, because of the number of folks that we have. so hospitals, hospices, skilled nursing facilities and all of the rest. i want every senior to know that while maybe it is technically accurate again for my friends across the aisle to claim that this bill doesn't cut medicare

benefits there is no way -- no way that you can slash a half a trillion dollars from payments to providers without affecting their ability to keep their door open. especially in rural and small-town america. seniors should know they will be left with a worthless benefit to paraphrase my friend, senator alexander from tennessee, it will be like having a bus ticket without a bus. thank you, senator johanns. thank you for the work that you are doing. thank you for this motion. i hope we are successful. i hope people will wake up and understand the severity of what these cuts will do. and i urge every member of this senate to support senator johanns when we come to a vote on this issue. thank you, mr. president. i yield the floor. mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: i heard that this is

going to hear from senators that this will hurt seniors, words like smoke screen and all of that. this is a well thoughtout considered policy that i think strikes a very good balance between getting care to -- especially to seniors at home, which is so important, on the one hand and making sure that there's not waste on the other hand. i mean, that is our responsibility here is to make sure that the program works an works well. i have sort after special interest in this. my mother's in the hospital, about two weeks ago, and she fortunately is doing much better. she's in the hospital. i spent some time with home health caregiver, who is doing -- with whom i was very, very impressed. this home health person was just doing a great job with my mother and -- and i've seen other instances too. but, personally, i was very happy to see my mother in very,

very good care from a home health care nurse. i think it is also important to just remind my colleagues that this amendment is really a retread on the mccain amendment that we debated over the last few days, generally. that is, once again the opponents of this bill are endorsing the status quo of medicare going on the brink of going bankrupt and seniors facing higher costs. i remind my colleagues again what will happen if we stick to the status quo, that is no bill which the other side is advocating. it means medicare will go broke in eight years. that's the status quo. in our legislation that is postponed for at least five more years. the status quo, with no bill with the other sides advocating, means seniors will continue paying higher and higher premiums and cost sharing due to wasteful overpayments to a good newsroom of -- number of health care providers. there is so much waste in our system, mr. president, we all know there is a lot of waste in our system, and frankly i'm

quite surprised that not all of our colleagues want to cut out the waste. in effect, they want to keep the waste. that's unfortunately in our system. the status quo also means that each year billions of medicare dollars will continue to be wasted on lining the pockets of private insurance companies, and that might be a bit of a strong statement, but the fact is that that -- is that some chief executives of private insurance companies are paid millions -- tens of millions of dollars to manage medicare programs, especially medicare advantage, and that the status quo means that will continue. the status quo also means that seniors will continue struggling to pay for prescription drugs. mr. president, the stakes of seniors in the medicare program have never been higher. we have a choice here, mr. president. it's a very simple choice. either endorse the status quo or strengthen medicare.

let's talk a little bit about home health care. regarding medicare changes for home health providers, let me describe what is in the senate bill. i don't think our colleagues really know specifically what's in the senate bill. that may be a strong statement to make, but i think if they knew what was in the bill, that some of the statements made tonight might be a little bit different. as most of my colleagues would agree, home health care is extremely important. it's a very important benefit in the medicare program. we are all very strong advocates of home health. across the country, there are more than 9,800 home health agencies that provide care to seniors in their homes. this care helps seniors get better, it helps them avoid expensive rehospitalizations. we're all champions of home health. we like people not to be institutionalized. it's much better where appropriate to have care in the

home and home health care agencies have provided that. it's so, so important. in my state of montana, home health care providers go the extra mile, literally, to provide care to patients across vast distances. in some cases, home health providers in rural areas have to drive 100 miles just to see one patient. they're dedicated people. they go great distances and travel a long way to see very few patients. home health providers make a real difference in improving seniors' health and we should support their efforts, and we all do. we all very much support their efforts. we'll have great respect for the services of home health -- that home health providers give. we also have the responsibility to protect the medicare program. we have to root out waste. and unfortunately, there is almost always some waste somewhere. it's a matter of judgment as to how much is waste and how much is not. we must make sure medicare is paying appropriately.

that is, medicare is not over paying for medicare services. we also must take action to root out fraud and abuse generally where it may occur in the home health industry as well. the policies in this senate bill i think achieve both goals. so what do we do in the bill? first, the senate bill would rebase home health payments to ensure payments reflect actual costs of providing care. these changes are based on recommendations by medpac, the independent advisory commission which advises congress on medicare reimbursement. it's a nonpartisan group. medpac advises rebase home health payments. what do we mean by that? when the current home health payments were set, seniors received an average of 31 visits per episode. today they receive 21, 22 visits as they get paid for doing less, frankly -- actually get paid about the same for doing less.

we're trying to make sure the payment reflects the actual services provided. so the senate bill directs the c.m.s. to rebase payments to reflect this change. it's common sense. medpac recommended it. medpac thinks it's got to keep up with the times because times have changed over the years and that the payment systems reflect that change. something else i think is very important as most of my colleagues agree with. that is the senate bill roots out fraud that unfortunately exists in home health care as well as some areas of medicare spending. it roots out the fraud -- it tries to root out the fraud and medicare payments for outliar cases. medicare provides an extra payment today to providers, home health folks who treat sicker people or otherwise known as outlier patients, really sick.

fortunately, the -- unfortunately, the general accounting office found that some providers were gaming the system and getting much more outlier payments than they deserved. for example, the general accounting office found in one florida county alone, home health providers were receiving 60% of all total outlier payments. that's nationwide, one county getting 60%, even though the county had less than 1% of a total medicare population. i don't want to just single out florida, but there are some other counties, they tend to be in the southern part of the country which clearly have grossly, grossly disproportionate amount of outlier payments, they are gaming the system. we addressed this problem by placing a cap on the amount provided by the payments. the senate bill also makes changes in 2007 and 2012 recommended by medpac. why is that important? medpac was actually much

tougher. they wanted to start right away in 2010. no, we'll hold off a little bit. we wanted to be fair to the home health providers. in addition, the bill establishes a productivity adjustment for home health providers beginning not right away, not next year, not the following year. it doesn't begin until the year 2015. these changes as home health providers like all others offer more efficient and higher quality care over time. being very fair about it. very importantly, in making these changes, we worked very closely with the home health industry to ensure that these changes were reasonable and they were fair. let's take each of the policies and what they do with respect to the agencies to make sure we're fair. on rebasing, medpac recommended we fully implement these changes in the year 2011. to ensure that providers could adapt to the new payment rates, we in the senate decided we would phase in these changes

over four years. home health providers support this phase-in. they think it's a good idea. on the outlier policy and the fraud changes, these policies were actually suggested to us by guess who? by the home health industry. they came to us and said we suggest that you make some changes in the outliers because too many agencies and home health providers are gaming the system. make some outlier changes to stop that gaming. make some changes to stop the fraud, so they came to us and they gave us some ideas. obviously, the home health industry fully supports the changes that they recommended to us. and they're in this bill. on the market basket and productivity changes, the senate bill holds off in applying these reductions as we delay these reductions while the rebasing policy is taking effect. again, we want to be fair. this bill gives home health agencies extra time, much more time than is recommended by very aggressive proposed changes,

proposed by medpac, very aggressive changes proposed in the house bill and by the administration. he is saying no, those are too aggressive, so we in the senate decide to give agencies extra time to adapt these payment changes and this -- rather than having all these implemented at the same time as medpac and the house and administration all would -- would recommend. and finally, with respect to rural home health providers, we're all very sensitive to the rural -- the special needs of rural america. so what do we do about that? well, from the years 2010-2015, rural providers receive 3% extra payment each year. this is a payment that will ensure that rural providers are protected as we reform the broader home health system. so an extra 3% from the period of 2010-2015 for rural providers. so in total, the home health changes in the senate bill, i

believe, strike a fair balance between ensuring seniors have access to home care and also rooting out inappropriate payments from this system. now, i previously heard my good friend say, well, gee, these changes are really going to hurt seniors. they're not going to hurt seniors. in fact, most of these changes are changes suggested by the home health care industry. i think that all of us want to root out fraud and waste. opponents also sometimes claim that the medicare beneficiaries will be harmed in lots of ways by this bill. that's a scare tactic, mr. president. let me say what the american association of retired persons says about these kind of claims, that is the claim that these changes in medicare reimbursement are going to harm seniors. the aarp says, and i quote -- "opponents of health reform won't rest. they are using myths and misinformation to distruth the truth that medicare will be harmed. after a lifetime of hard work, don't seniors deserve better?"

that's a statement by the aarp. i don't suggest here tonight that any of our colleagues are using myths and misinformation to distort the truth, but the main point here is aarp when it hears claims that seniors are going to be hurt says that's not true, and they support this bill, they strongly support this bill, i might add. so let me remind my colleagues of some of the positive changes in this legislation. this legislation approves the solvency of the medicare program by five years. it puts $30 billion back into the pockets of seniors in the form of lower medicare premiums. it makes prescription drugs more affordable. that's an added bill that would not be available if this legislation was not passed. the bill guarantees seniors can continue to see the doctor of their choosing. the bill provides free wellness and prevention benefits. those are new benefits that don't currently exist. it also includes fair to appropriate changes to home health as i suggested that protect access to care. i don't question the motives of my colleagues. they believe they are standing up for seniors in opposing these

home health changes, but in truth they are really going to harm seniors because they are hurting the medicare program, and i don't think we want to hurt the medicare program. rather, we're trying to help the medicare program by making these changes. one other point i want to make that's just kind of interesting, i thought, when i saw it, if i still have it. it's kind of interesting, the growth rate in home health care spending will continue to be very high after this legislation passed. it will -- it will be 10%? the growth rate per year under this bill with changes -- or currently, excuse me, currently the growth rate of home health care industries is almost 11% per year. after this legislation, it will

be almost 8%. 8% annual growth in the home health care industry, and that's much faster than national health expenditures. so i think -- most things in life are a judgment call. i think we will fairly decide the changes we make in this bill are good for seniors, they are good for home health, because they are sensitive to the needs of the industry, sensitive to patients, frankly, but also responsible to the american taxpayers by making sure we're rooting out a lot of waste. mr. cornyn: mr. president? the presiding officer: the senator from texas. mr. cornyn: thank you, mr. president. mr. president, i think as the american people are listening to the debate we're having on -- on health care reform, they are

being asked to accept some pretty implausible claims. one claim that you can take half a trillion dollars out of medicare and it won't have any impact on the delivery of services to medicare beneficiaries. half a trillion dollars. and the biggest mistake, i think, about the way this bill is paid for with the huge tax increases and with huge cuts in medicare is that the proposal is to let's take half a trillion dollars out of medicare, including $40 billion out of home health care, in order to pay for a brand-new entitlement program when we already know that medicare itself is on a fiscally unsustainable path. well, i want to talk primarily about another aspect of -- of

this -- of these cuts, and that is the 11 million seniors, including 532,000 texans who will lose benefits under their medicare advantage program because these are not inconsequential cuts in their benefits. they're serious, and i want to talk about some real human beings, some real texans who are going to be affected in the negative -- negatively by these cuts. first of all, i think it's absolutely critical for the american people to understand that pher itself does not provide complete -- that medicare itself does not provide complete coverage. that is why some seniors buy medigap in order to get their bills paid for because medicare

pays on average about 80% to providers what private health care insurance does. that's the reason why without additional compensation many doctors won't see a medicare patient because they simply cannot do it and keep their doors open to their other patients. the truth is medicare advantage was created to fix some of the flaws with medicare fee-for-service to give seniors more affordable and better coordinated health care, which none of us are standing up here and saying that the proposed bill is all bad, because some of the positive developments in this bill call for greater coordination of health care. but, on balance, it makes things worse than it does better because of these cuts in things like medicare advantage. the president of the united states has said that providing americans with a choice of quality affordable health care was a guiding principle for him,

and i agree with that statement of principle. medicare advantage was created for that very purpose, because, as i said, medicare itself does not always work well for patients. where i live in austin, texas, which is travis county, last time i saw a report, only 17% of physicians will see a new medicare patient because medicare reimbursement rates are so low. those problems are avoided in large part by medicare advantage because it pays physicians and providers better than medicare fee-for-service. according to the american medical association's 2008 national health insurance report card, medicare -- not private health insurance -- but medicare had the highest percentage and the largest number of denied medical claims. in fact, medicare denied ten times more medical claims than

private insurers. that's another reason why seniors deserve a choice between medicare and private plans that will offer them better benefits. as i mentioned today, 11 million americans have made that choice of better benefits and better care coordination through the medicare advantage program. the proposed bill, the reid bill will take away those choices and the benefits of those 11 million seniors by cutting about $120 billion from the program. now, many of our friends across the aisle will say we can cut $120 billion out of medicare advantage and it will have no impact on delivery of services, but the congressional budget office disagrees with them, the director does, who said that their benefits, their additional benefits will be cut roughly in half. we need to set the record straight on these so-called overpayments allegedly going to insurance company profits. it's simply a false statement.

it's not true. our colleagues know that the so-called overpayments to medicare advantage plans don't go into those plans. they go to seniors in the form of additional benefits. that's because under federal law, 75% of additional payments to medicare advantage plans are used to provide seniors with additional benefits, benefits which they would not get under medicare fee-for-service. things like chronic care management, hearing aids, eyeglasses, and the like. anded other 25 -- and other 25% of any extra payments is returned to the federal government. so let's be clear, cuts to medicare advantage would be taking away seniors' health benefits for those 11 million seniors. as i mentioned 500,000 texans are on medicare advantage and the reid bill would cut their

benefits by well over half. you don't have to take my word for it. listen to what the c.b.o. director, dr. elmendorf, said, when senator crapo asked him during the finance committee hearing, he said approximately half of the additional benefit would be lost to those medicare advantage policyholders? dr. elmendorf said -- quote -- "for those who would be enrolled otherwise, under current law, yes." nearly one out of every four seniors in texas would lose about $122 a month in health care benefits to create a new $2.5 trillion entitlement that their grandchildren will ultimately end up having to pay for. $122 a month may not sound like a lot to people inside the beltway, but a couple from my hometown of san antonio recently wrote to me saying, "please vote to leave our medicare advantage plans alone. we can't afford anything else as our portfolio is wiped out in

the stock market collapse last year. my wife and i have had to go back to work, and we are in our 70's." and yet this bill would impose another $122 per month cut in their benefits. another constituent of mine from conroe, texas, wrote "please do what you can to probing the medicare advantage -- to protect the medicare advantage plans. i'm on one. it's saved me an enormous amount of money and given me the benefits that i've needed." some groups that support these cuts to medicare advantage have a conflict of interest, to say the least, because the benefits under traditional fee-for-service, as i mentioned, for medicare is about 80% of what private insurance will pay in order to get coverage, in order to pay the bills many seniors have had to buy additional insurance coverage. for 11 million seniors, medicare advantage provides those benefits. for many seniors, former

employers sometimes provide wraparound plans for retired military, tricare provides a wraparound plan. for many very low-income seniors, medicaid helps with cost sharing and premiums. and for many other seniors they purchase a standalone medigap policy. we heard from friends across the aisle about aarp's medicare cuts in the reid bill. if it sounds odd that a seniors' advocacy group would support taking nearly $500 billion from an already nearly bankrupt medicare program, it should. the fact of the matter is, as "the washington post" noted on october 27, the "post" says but not advertised in its lobbying campaign have been aarp's substantial earnings from insurance royalties and the potential benefits that could come its way from many of the reform proposals.

democratic proposals to slash reimbursements for another program called medicare advantage are widely expected to drive up demand for private medigap coverage, like the ones offered by aarp, according to health care experts, legislative aides and documents." so aarp, the so-called seniors' advocacy group that's advocated for cut in the benefits to 11 is million beneficiaries of medicare advantage, a suggestion is one reason they will do so is because they will profit from this bill because these seniors will, if they can afford it, have to go out and buy medigap coverage from, lo and behold, entities like aarp. the fact of the matter is medicare advantage allows private plans to innovate better and provides better coordinated

care for seniors. groups like the kelsey seabold clinic in houston, texas, which is basically not seeing medicare fee-for-service patients but is seeing medicare advantage patients because they can afford to coordinate care, the kinds of things we know they ought to be doing to provide better care, but they can't afford to do it on the fee-for-service of medicare. we've had the medicare program around for more than 40 years, and the fact is that government bureaucrats are still trying to get the complex reimbursement formulas right. we know, as the distinguished chairman of the finance committee has said, that under the fee-for-service program, which is part of what needs to be reformed in this health care bill, medicare pays for volume and not value. now, some of the positive things which i've complimented the bill

on is it includes some small steps to change our current pay for volume program to a pay-per-value aptproefp through various deliver system reform demonstration programs. the irony is medicare didn't think of these system reforms. rather, washington is finally catching up on what private-sector innovators have been doing for years. we heard the distinguished senator from minnesota talk about the mayo clinic. mayo clinic's has been doing that. i mentioned kelsey seabold in houston, texas. private-sector innovators have been doing this through the medicare advantage program already. the delivery system reforms in the reid bill would allow medicare to experiment with different approaches to changing physician incentives such as accountable care organizations or physician quality reporting initiative. will they work? well, i happen to think they will. but we do know that

private-sector innovators have already figured out how to change physician incentives in the sorts of ways that we really ought to be doing more of and not punishing by cutting medicare advantage. one medicare advantage plan health spring serves 20,000 seniors in my state. they have been a leader in changing the incentives for physicians to focus on quality rather than quantity. i met with their leadership and heard how they've done it. what they've knolled me is they're -- told me is they are a collaborative partnership with their physicians. they call it partnership for quality. physicians are accountable for both cost and quality based on evidence-based sets of quality measures. the results are a win-win. better quality care is leading to healthier seniors and physicians to succeed in meeting evidence-based quality standards and ultimately lower health care costs, which i thought was supposed to be one of the goals

of health care reform. participating physicians were paid financial incentives for meeting their goal, but as a result of coordination of care and evidence-based quality standards, they actually ended up charging less. and patients experienced better results too. members needed fewer hospitalizations and emergency room visits. preventive measures increased mammograms by 80%, diabetic foot exams by 360%, and flu vaccinations by 246%. i've heard about health springs success from a couple at farmers branches, texas, who recently wrote to me. they said we had a medicare supplemental policy for several years until they priced themselves out of the market. for now with a medicare advantage plan called health

spring, and we've been very happy with this plan and the way they are saving us money. please do not change or eliminate this program, they said. let me tell you about one other texas company called wellmed. while the reid bill would finally give medicare the ability to experiment with medical homes and care coordination, a san antonio-based company called well med has been using a medical home model to coordinate patient care and emphasize prevention for nearly 20 years. to quote from an article last month in "inside san antonio," the health care delivery model at well med puts the patient at the center of the team directed by a primary care physician. that team may include a nurse, a health coach, a hospitallist, a social service worker and a physician assistant. according to well med's c.e.o., we really do have to bring back the old-time primary care

doctors who cared for you, who is concerned about you, who is part of your family and you were part of their family. it's the primary care physician who knows all about you. so if you need a specialist, if you know -- they know the best specialist to send to you. if you need to go to the hospital, they make sure you get the appropriate care at the right hospital. they are a coordinator of your care. and that's really the concept of the medical home. there's no question in my mind that this model has been saving lives in my state. here's a story about one texans whose life was saved by physicians caring for him at well med. "for years crohn's disease weakened" -- we'll call him ed -- "and left him susceptible to infections. one morning in 2001 he lacked energy to even get out of bed. his breathing bake labored and

he developed -- became labored and he developed a cough which sounded wet. his worried wife called his primary physician at well med who wanted ed hospitalized immediately so she could order a nuclear scan of his lungs, but he protested. she told me if he refused to go i should call 911 and have the paramedics come get him. his wife, annette, said she heard dr. sanchez talk to go me. the urgency in h -- the scan confirmed the doctor's suspicion: a potentially fatal blood clot had traveled from his leg to his lungs. fortunately, he was successfully treated and recovered and ed and his wife recently celebrated his 74th birthday. now, annette credits dr. sanchez for saving her husband, ed's life and for acting as a catalyst that keeps him thriving

even in his golden years. she said, we've seen an abundance of doctors from the cancer doctors to the dermatologist, gastro enterologist, the blood doctor, the heart specialist. ed has gone through it all. and they've all been coordinated by his primary care doctor. i've been to other doctors outside of well med and you don't get the feeling that they are communicating like this. well, many texas seniors currentlien joy these extra benefits under medicare advantage like another benefit -- like the silver sneakers program, the nation's leading exercise program for older americans. this past year one of the silver sneakers members personally visited my toffs deliver testimonials from other silver sneakers members. one said "at my age, i need a program to strengthen me all over but primarily to help me keep my balance and

coordination. i need these skills to keep me from falling and breaking my bones." another participant in the silver sneakers program said, "i'm 66 and i've been on the program for a year. prior to that i'd had had a sedentary life which included many problems: hypertension, mild depression, high blood pressure. since coming to the class, my life has improved immensely. my blood pressure has dropped, my cholesterol has been lowered, my chronic bladder condition has improved and i just feel better all around. i'm no longer depressed because i look better and i look forward to going to class and visiting with my friends." well, mr. president, these cuts in medicare advantage are going to have a direct impact on the benefits that my constituents in texas are benefiting from, the

532,000 texans who are currently on medicare vafnlgt what they're asking me and which i can't answer them is, why in the world would we want to cut medicare advantage, which is actually -- which actually works as opposed to medicare fee-for-service which does not work well, to take a fiscally unsustainable program like medicare, which is going to go insolved in 2017 and use that to create a $2.5 trillion new entitlement program? now, my constituents, the seniors who paid into medicare all these years, are saying, it's not fair to take the money that we paid into medicare, to use it to create yet another entitlement program and not to fix medicare itself. so i believe that we need to fix medicare's nearly $38 trillion in unfunded liabilities.

we need to fix the improper payment rate of roughly one out of every ten medicare dollars, which results in probably somewhere around the order of a minimum of $60 billion of fraudulent payments each year. we need to put it on a fiscally sustainable path rather than taking a half a trillion dollars from medicare on another ill-conceived washington health care takeover. i just don't believe, mr. president, that my constituents believe that you can take a-a trillions out of these programs scwus as they don't believe that you can take more than $100 billion out of medicare advantage and it will have no impact on there -- on their benefits. they just don't buy it. they just don't believe it and i don't either. mr. president, i yield the floor. the presiding officer: the senator iowa. mr. grassley: mr. president, it is late in the evening.

i was going to address three different issues tonight, but out of respect for senator baucus, the chairman of my committee, i'm going to address just one of the issues and i'll come back tomorrow morning on saturday and speak on the rest of the issues. so i'm going to -- the one issue i'm going to address this evening is to support the senator from nebraska's motion to commit with instructions on the home health care aspect of this 2,074-page bill. that's senator johanns' amendment. we're now considering a bill that cuts a half a trillion dollars from the medicare program to fund yet another unsustainable health care entitlement program. around $42 billion comes from cuts to home health care providers. hence, the purpose of senator johanns' amendment that that not

happen. you've heard from members on this side of the grave consequences of these cuts. several senators have already addressed these. these severe cuts pose a legitimate threat to beneficiaries' access to home health services. in my state of iowa alone, there are around 160 home health agencies that provide valuable services to medicare beneficiaries across the state. now, thanks to these home health care providers, seniors in iowa are able to continue to live at home instead of in institutional settings like nursing homes. these seniors place great value on being able to stay home, and i'd have to say in all the years that i've been involved in senior issues, whether it's been chairman of the aging committee,

chairman and now rarchging member of the finance committee, i haven't run into one single senior citizen in my state that said to me, i'm just dying to get into a nursing home. they don't want to go there. so, that's the purpose of home health agencies, to save money but also to retain quality of life and maintain quality of life. for these citizens. i rarely hear ey iowans say anything about living in a nursing home except not to go there. and since living at home has been found to be a more cost-effective alternative than institutional care, this results in medicare spending less. these cuts that are in this 2,074-page reid bill will make it even harder for iowa home

health care providers to care for medicare beneficiaries. a good part of medicare health cuts come from productivity adjustment. let's look at the possibility -- or i'll say, i've concluded, the impossibility of bringing greater productivity to nursing home care. you've heard this week about how medicare's chief actuary found that savings from these productivity adjustments to be very unrealistic. and just so you know that the letter i refer to from the chief actuary is real, just observe this chart. you also heard this week how these permanent cuts would make it harder to provide for

providers to remain in the black. and you also heard these providers might end their participation in medicare and possibly then jeopardize access to care for beneficiaries and probably then more people ending up in the more expensive environment of a nursing home. the threat to access home health from these permanent productivity cuts isn't theoretical. it's real. like many other medicare providers, home health agencies provide labor-intensive services. and because of these labor-intensive services, that's why i raise the question and the possibility -- and i say it ends up being an impossibility -- to really be more productive. because there are few gadgets in home health that will increase

productivity. and whatever available gadgets are unaffordable for many iowa home health agencies, because they are small operations with limited financial resources. home health care is about doctors, it's about nurses, and home health aides, and it's about all of these providing care to the most needy. so, it is incorrect in my judgment to assume that these providers will achieve the levels of productivity, like the rest of the economy. the h.h.s. actuary's -- chief actuary's findings clearly apply to home health in my state of iowa, like they do nationally. just to remind you, "the

estimated savings may be unrealistic." and, "possibly jeopardizing access" for our seniors. more people in nursing homes. because of these cuts, the percent of iowa home health agencies that have negative medicare margins will increase to 75%. so over 120 of the 160 home health providers will have negative margins because of this 2,074-page reid bill. and iowa providers are not alo alone. from one half to 90% of home health agencie agencies agencies the country would have negative medicare margins. i have a letter here -- i'm going to make one request for three inserts that i'd like to put in at various places in my

remarks. but so i would ask that permission, mr. president. the presiding officer: twowks. mr. grassley: i have here a letter dated september 23 from -- from september 23 of this year from the president of the national association of home health and hospice. this organization represents health agencies across the country. he wrote this letter in response to the $43 billion in home health cuts in the finance committee package, which presumes to be the same number that is used in the reid bill. in this letter, he stated, "it is crucial to the survival of home health services' delivery system that you work to reduce the $43 billion in cuts currently contained in the senate finance committee's health reform package. our analysis indicates that by

2016 the proposed cuts in home health services payment rates will lead to nearly 70% of the provider's nationwide at risk of closing because their costs will exceed medicare payments. if that occurs," the letter says, "president obama's promise that medicare beneficiaries will not be adversely affected by health care reform will be broken." end of quote. i have yet to hear from a home health provider in iowa that these permanent cuts will make it easier for them to care for their medicare beneficiaries. and instead i hear that these cuts would reduce access to home health services. so i have the second letter that i just asked to have inserted,

and that letter is from the iowa association of home care, and they wrote, "ensuring that medicare home health payments are not further reduce -- reduced further is essential to avoid the resulting limits or no access to home health services for many iowans who prefer to receive services in their home." end of quote. so, as the chief actuary -- as the chart shows, not just the chief actuary saying it, but people that are connected with the business of home health care say it, these permanent cuts will in fact jeopardize access

to home care in iowa. so, if the home health cuts in the reid bill are allowed to go into effect, then iowa's seniors who prefer to live full lives from their homes will be forced to live in the more expensive settings, like nursing homes. i believe that many members on both sides of the aisle share my concern about home health care cuts. i have here a letter -- the third letter i referred to. now, this letter is from july 27, 2007, and it's written to senator baucus and me. but the reason i use this letter, even though it's two years old, we were getting entreaties from 61 of our colleagues, of which 52 now serve -- still serve in the united states senate, about a

legislative proposal to cut medicare home health payments in that year, 2007, by $ 9.7 billion and hospice payments by more than $1.1 billion. they urged me and senator baucus at that time to ensure that home health and hospice providers receive full market basket inflation adjustments. they also urged us to oppose any cuts in payment rates through administrative actions. in the letter, these members stated that home health and hospice care -- quote -- "have been demonstrated to be cost-effective alternatives to institutional care in both medicare and medicaid programs and they stated that -- quote -- "reducing medicare home health and hospice payments would place the quality of home health care and hospice and the home care

delivery system at significant risk." of these 61 senators that signed this letter two years ago, 52 are currently here debating this bill in the united states senate. and of those 52 senators, 37 are from this side of the aisle that are now proposing $43 billion in cuts instead of $9.7 billion in home payment cuts and $1.1 billion in hospice payment cuts, as i would think that they would find these kind of cuts three or four times -- four times what we were talking about two years ago to be very, very unrealistic and to keep home health as a viable organization going. we also must look beyond health

care when we look at the impact of these permanent cuts. i've also heard from providers in iowa that permanent cuts like this will make it even harder for them to keep their doors open. so around 3,500 iowans who work in home health agencies are at risk of losing their jobs at the time we have 10% unemployment. at a time when more of this country is concerned that congress ought to be working on creating jobs, jobs, jobs as opposed to the health care issue and in some cases cutting jobs out. the labor department reported yesterday -- or today it was that unemployment is 10%. now is not the time to consider bills that increase unemployment rates. so about an hour ago, the senator from nebraska has offered this motion that i'm speaking in favor of now to send this bill to the finance

committee with instructions to report a bill without these very enormous home health cuts that are in it. we should take this opportunity to fix the bill and then come back it full senate with a better bill. that's why i support the senator from nebraska's motion to commit and i urge my colleagues to do the same. i yield the floor. mr. sessions: mr. president? the presiding officer: the senator from alabama. mr. sessions sessions: before tr leaves, he's a man of great character and experience in these matters, and i have a letter from a constituent who writes to urge -- to quote -- "urge you to vote against this health care bill." this is from mr. bill ebberly in huntsville, alabama. he says, "the worst part of this bill is that most of the cuts will be paid for by cuts to medicare." i think the senator indicated he believes that accurate. he goes to say -- quote -- "i am

68 years old and i have paid into medicare for 40 years believing it would cover much of my health care costs when i became 65. now i am being told that the government has found people who need the coverage more than i do. and they will cut the care for which i have paid for 40 years in order to cover people who have paid nothing into the program. it's not the government's money. the money belongs to those of us who paid into for so many years and are watching as it is being taken away from us." and i guess my question to you, since you've been so intimately involved with medicare over the years, is it not true that every working american has money taken out of their paycheck to fund their medicare -- medicare and that they believe and we have a

compact with them that when they reach 75, they will have the benefit of that. mr. grassley: 65 they get the benefit of it. mr. sessions: 65, yes. mr. grassley: yes, to the tune of 2.9% of payroll. that's what a self-employed person would play. and an employee would pay 1.45%. and the employer would pay 1.4 1.45%. and you know this 2,074-page bill adds a half a percentage appoint to those. so you're going to get it to a point where it's almost 2% for the employer, 2% for the employee and it would be almost 4% for a self-employed person paying into this fund that is now going to be raided to -- to finance a brand-new entitlement program. mr. sessions: so my constituent is fundamentally correct in his

concern? mr. grassley: well, there's a great -- i sense a great deal of resentment in that coming through in the words of that letter from that person, that what he's paid into for his probably 40 years that he was working, or maybe 45 years that he's working before he retired, that -- that now with medicare already being in jeopardy based on the trustees' report which says by 2017 that there's not going to be any money in the trust fund, and then having $464 billion taken out of that trust fund to help finance a new entitlement program at a time when the present entitlement programs are in some -- a great deal of financial jeopardy. mr. sessions: i think you stated that so well. and just to reemphasize, that judge, mr. ebberly, who paid in are for 40 years into medicare, until he got 65, he got not a dime of medicare benefit, did

he? mr. grassley: no. the only way he would have got benefits is if he had become disabled before age 6567895. mr. sessions: so he pays in all these years and just now gets to draw it and start taking it out. well, i want to thank you, senator grassley, for your leadership on this issue. and i think you and i kind of come out of the soil of our states, out of the real world, and my impression is that nothing comes from nothing. would you agree? somebody's got to payment mr. grassley: say it this way. we're in a town where we're dealing way lot of washington nonsense and i hope from the rural areas of alabama, like the state of iowa, you bring a lot of commonsense to this town where there isn't a lot of it. mr. sessions: thank you, very much. mr. president, i just would say that the matter is a very serious one that we're dealing with.

i today had the opportunity to talk about a -- talk to a very experienced person involved in health care issues for many years, and i expressed my bafflement about some of the disagreements we have about huge issues. and one of my staffers wrote it down what he said. he said, in all my years, i've -- quote -- "never seen such transparent dishonesty in the congress." he said, it's the biggest fraud that's been perpetrated in the history of our country, in his opinion. i mean, so here we have a situation -- i just want to say i'm going to pursue this a little more, in more great detail, and i'm not going to go into it here tonight, but we had an amendment -- senator bennett had an amendment yesterday that said we wouldn't cut guaranteed benefits. and, well, the way this -- for

medicare. but the way this deal is being done is they're cutting payments to providers of medicare, and we are already reaching, as senator grassley said, a national crisis, because by 2017, we won't be able to have a surplus in medicare. we're going into default in medicare and where are we going to get the money. well, could we have efficiencies, could we save some money in medicare, could we do some things to keep the program afloat? perhaps. but if we do so, should we not use it, shouldn't we not use any efficiencies and savings that we could scrape together without damaging the commitment we have to our seniors? shouldn't we use those savings to save medicare, that's going into detaught? i suggest -- that's going into default?

i suggest that's a moral and legal commitment. as this mr. ebberly has written to me, he's paid for 40 years. he's not been able to draw anything out of it, for 40 years as he's paid into it. and now he gets ready to draw, we're telling him we're going to cut $465 billion out of the medicare payments. and this is not a little, bitty matter. and we seem to have, amazingly, we seem to have this dispute. and one group from the other side says that, don't worry, we're not taking $465 billion from medicare, and we wouldn't cut medicare, and we don't believe in cutting medicare, and we don't want to hurt medicare in any way. and our side's over here saying, but you are. now, according to the numbers that we've -- that are pretty

plain in this legislation, hospitals will have $134 billion reduction. hospices, as the senator -- spises, yohospices, $7 billion, life-ending care that has been so helpful to so many people. nursing homes, $15 billion. home health agencies that senator grassley talked about, $42 billion reductions. are we imagining this? is this somehow we've just formulated this up? it all totals up to about $465 billion. so this matter i suggest is not going away. either we have reality here or not. i believe that the facts will show that we are raiding medicare, we are weakening that program when it is already known

to all of us in this body that medicare is not actuarially sound. i remember when president bush determined in a failed effort to try to alter social security in a way that he felt would put it on a sounder footing, got no help at all. we had many of our senators on both sides of the aisle saying, well, if you really want to do something bad as social security is, medicare is in much worse financial fix. why aren't you fixing it? i remember a number of years ago, ten or more, when senator judge gregg, then chairman of the budget committee, tried to come up with some legislation to contain a little bit of the growth in medicare, and over $5 years he had a plan that would contain the growth by $10 billion. not a single democrat voted for the gregg proposal. every bit of it.

and they had accused the republicans of trying to damage medicare when, in fact, every penny of the $10 billion to be saved was going to be utilized to strengthen medicare and try to keep it from going in default. so now we're talking about taking $465 billion out of medicare and starting a new entitlement program, a new entitlement program at the time that this nation has just passed -- or just incurred the largest single deficit in the history of the american republ republic, $1.4 trillion. and next year we'll be over $1 trillion, according to the congressional budget office. not me. so is this smart to have a program that people have

depended on, that we have a moral compact to support our seniors who paid into this plan for 40 years now taking money out of that to create a new program? it is, in fact, in quite a number of areas going to cost far more than is being suggested by the people who are promoting the legislation. we're going to dig into this and try analyze it with more clarity. but the truth is the numbers just don't add up. they won't work. we -- we just ought not to be establishing a new entitlement program of massive proportions in a way that we really have little concept of how it's going to play out at a time of the largest deficits this nation has ef her. -- ever had. deficits that according to our own congressional budget office will double the national debt in five years an triple it to dz --

and triple it to $17 trillion in 10 years. it is an unsustainable course. and one of the first things you have to do is watch how to you spend your money. i talked to an individual today. he said it's like your house is in serious need of repair. you really don't have the money to fix it. you finally decide you've got to borrow money to fix the house and instead you borrow money and add a wing on to the house. we need to fix the house we've got. we need to make sure that we honor our commitment to medicare recipients. you see, they've already paid. that's the important point to remember. they already paid their working life under a compact and a commitment that that money would be in the fund to take care of them and we ought not to take it

away. i urge my colleagues to think about this. and this is just perhaps the most significant fatal flaw in the legislation. it just doesn't add up. there are a lot of others. but this one, to me, is the most dramatic, the most pernicious, the one that is most unwise. and we simply need to slow down, ask ourselves how we can make our health care system better. how we can do it without breaking the bank. aren't there some things that we can do to improve health care in america without a huge cost? yes, there are. and let's start with every single one of those that we can agree on and if we do that, i think that we can make a lot of progress. and who knows, if this economy turns around, and we all hope it will, we'll be in a better footing to consider something -- consider a new benefit in the future. i would thank the chair and yield the floor.

the presiding officer: the senator from montana. mr. baucus: i ask consent that the senate proceed to a period of morning business with senators permitted to speak up to 10 minutes each. the presiding officer: without objection. mr. baucus: i ask that the committee on homeland government affairs -- the bill referred to the committee. the presiding officer: without objection. mr. baucus: mr. president, i ask consent that the senate proceed to the immediate consideration of calendar number 212, s. res. 341. the presiding officer: the clerk will report. the clerk: calendar 212, s. res. 341, supporting peace, security and innocent civilians affected by conflict in yemen. the presiding officer: without objection, the senate will proceed to the measure. mr. baucus: mr. president, i ask unanimous consent that the resolution be agreed to, the preamble be agreed to, the motion to reconsider be laid on the table with no intervening action or debate and any

statements related to the resolution be placed in the record at the appropriate place as if read. the presiding officer: without objection. mr. baucus: mr. president, i ask unanimous consent that the senate now proceed to the consideration of s. res. 370, which was submitted earlier today. the presiding officer: the clerk will report. the clerk: s. res. 370, relative to the death of paula f. hawkins, former united states senator for the state of florida. the presiding officer: without objection, the senate will proceed to the measure. mr. baucus: mr. president, i ask unanimous consent that the resolution be agreed to, the preamble be agreed to, the motion to reconsider be laid on the table. the presiding officer: without objection. mr. baucus: mr. president, i ask unanimous consent that when the senate completes its business today, it adjourn until 10:00 a.m. on saturday, september 5. that following the prayer and pledge, the journal of proceedings be approved to date, the morning hour be deemed expired, the time for the two leaders be reserved for their

use later in the day and senate resume consideration of h.r. 3590, the health care reform legislation. that the first three hours following any leader remarks equally divided between the two leaders or their designees and controlled in 45 minute alternating blocks of time. with the majority controlling the first block and no other motions or amendments in order during the controlled time. the presiding officer: without objection. mr. baucus: mr. president, senators should expect roll call votes tomorrow afternoon. there will be no roll call votes require prior to 1:00 p.m. i ask that the senate adjourn under the provision of s. yes 3 -- s. res. 370 for paula hawkins, the previous senator for state of florida. the presiding officer: the senate will adjourn until 10:00 and s. res. 370, does so as a mark of respect for paula hawkins, former senator from the state of florida.

the senate is adjourned. we talked with a capitol hill reporter about the continuing debate on health care. >> alex wayne is with congressional quarterly, the senate is continuing

deliberations on health care, how is the work going? >> well, it's agonizingly slow. they've been talking for a week about this bill and haven't voted on any amendments of substance, they voted on four amendments today, two of them failed into past but the to the past really wouldn't do anything to the bill. >> anything significant about them? >> there was one that drew some democratic support to, they stripped and a pretty important provision of the bill. part of the bill would create long-term care program, it would give people a cash benefits if they become disabled and would require you to paint a monthly premium for that benefit to. a lot of republicans have criticized his program call that the class act because they think it will become a bigger drain on the treasury and is one more entitlement we don't need so a couple democrats apparently agreed and voted to strip the class act from the bill at this

program. >> are we expecting more? >> they are supposed to vote on a few tomorrow. really we won't get into the big ones but everybody is looking to that next week, senator nelson planning of nebraska is planning to offer an amendment on abortion. who are going to eventually have amendments on public option but we don't know the timing of those yet. >> beyond the amendments have any senator step toward to discuss changes they like to see to this legislation? >> i just mention senator ben nelson, he wants anti-abortion language in the bill to be more restrictive. right now the bill would require private insurers and the public option to jump through some sort of accounting groups if they want to cover a portion of the have to ensure that they don't pay for with the federal tax dollars. ben nelson doesn't think that strict enough, he wants to forbid the public auction from covering a lack of abortion and he wants to prevent a public

insurance plans and that receive subsidies from the government from covering abortion also. >> you mentioned the senators will be in tomorrow and probably on sunday. will we get a sense of the republican strategy at any point this week in? >> i think the republican strategy is fairly clear in a broad sweep try to slow this down to a crawl and they want to keep hammering this point that in this bill would reduce medicare spending over the next decade and republicans say that's going to cut benefits -- lead to cuts in medicare benefits so basically they are trying to increase the concern of seniors who might already be a little suspicious of this bill. >> do you have a sense of what's going beyond the scenes as majority leader is working to get this past? what kind of discussions is he having? >> right now they're having a meeting in his office tonight as we talkç here. i believe the folks we counted going into that room included

senator nelson who i mentioned, senator mary landrieu from louisiana, senator pryor from arkansas, senator schumer from new york, one of the democratic leadership, senator russ feingold -- let's see who else -- in number of democratic members from both sides of the political spectrum, more liberal members and more moderate or even as a conservative, it's called moderate members are all in this room together right now hashing out some of these difficult issues. the most difficult, of course, our abortion and the public auction. >> what else can we expect as a the senate continues this weekend? >> i think he will see not very much public progress. they're going to vote on amendments tomorrow, we don't know whether they will vote on anything sunday. the real progress if there is any made it's happening behind closed doors and what's going on on the floor isn't really the important stuff. what's going on in senator reid's office is an important

stuff and unfortunately there are any c-span cameras in their. >> do we have a sense of when this might be wrapped up? >> we don't. democratic leaders are pretty candid they think it's fine to take most of the month. senator durbin told reporters today their goal is to pass a bill by christmas. i wouldn't expect it to happen much sooner and christmas eve or the day before. >> alex is with congressional quarterly, you can read some of his articles i congress did award. thank you for joining us. >> thank you. >> as we get better at what we do we run an ever increasing risk of all over confidence and arrogance. >> forbush currently sit on "the new york times" bestsellers less including his latest, with the dog saw, he is our guest 79 on c-span2 n/a. >> american icon, three original documentaries from c-span. now available on dvd.

now a discussion on the role of nato in afghanistan. from today's "washington journal", this is 30 minutes. >> host: our next guest is general george tillman who served from 93 to 97 as the supreme allied commander as afghanistan. first of all, you heard the president's speech on tuesday, will this new strategy worked as outlined by general gristle and others in the military? >> guest: the jury is still out and it depends on the

execution in implementation but i think the president laid out some clarity which i think is extremely important on what the goals are and what is required of the afghans in particular. in order to get to their security forces up for they can provide the nation's own security so the jury is still out but i think the objectives are clear and that to me has always been an important requirement. >> host: there is a meeting going on in brussels with secretary of state clinton represented the u.s. this morning, the secretary general of nato spells out a couple of specific points. one i want to get your reaction to, he says, to be clear transition is not a code word for exit strategy. it means transition into a different role. can you elaborate? >> guest: again if you read the president's speech i think he makes it clear we looked at this point that talks about july 2011 but he says that will allow us to begin the transfer

of our forces out of it afghanistan. who will execute irresponsibly taking into account conditions on the ground. so i think what we are seeing here is say that we will assess where we are at that point and how we began that transition depends on where the afghans are and i think nato is very important to there and i think they can help transition in this transition of training of the afghan forces. >> host: secretary rasmussen says it's not just president of, sort, the time magazine says it is his war. >> guest: is not. and when we went into bosnia nie five we have 37 nations, two-thirds of the force for other than u.s. of the 60,000 forces that went in. and there are 43 nations on the ground out in