subjected to the kind of scrutiny that this bill's been subjected to by the congressional budget office. so they may have good ideas. i can't say that they do or don't. but by and large, they are just taking pot shots at this bill. because they don't have a bill. you listen to the senator from arizona and he talks about taxes. he fails to mention one or two critically important things. first, this bill has $441 billion in tax cuts in the first ten years. for average people trying to pay their health insurance premiums. i don't know if the senator from arizona thinks that's a good idea or not. he's never spoken to that, at least that i've heard. i think it's a good idea. if you're making less than $80,000 a year, i want to make sure you have insurance, and this bill wants to make sure we give you a helping hand. it's a tax cut.

secondly, this bill provides tax relief with small businesses with fewer than 25 employees. those are mom and pop small businesses. this bill gives a tax break to those businesses. when the senator talks about this little tax and that little tax, he fails to step back and look at the big picture. the big picture is this bill changes health care in a positive way. it keeps the good things we have in america's health care system but it changes some of the things that need to be changed. this bill makes health insurance more affordable, and that's something every american wants. i have yet to hear a proposal from the other side of the aisle which does that. certainly nothing that has been subject to the scrutiny of the congressional budget office. this bill also expands to 94% of the american population the people who have health insurance. that is an all-time high. we've never had that many people insured in america. the senator from arizona just talked about a tax on medical

devices. why would industries like the hospital industry or medical device industry or pharmaceutical industry agree to pay more money to the government as part of this? for one very simple and fundamental reason: 30 million more americans will have health insurance. they will be using more fell devices and -- more medical device and paying for them with their insurance policy. they'll be using more pharmaceuticals. more hospitals will get paid instead of relying on charity care. so many of these providers have stepped up to us and said if the goal is to expand the base of people insured, paying into the system, our industry, which provides medical services, medical devices and that sort of thing, is willing to participate to, come up with the money to make this work. that's the part that the senator from arizona did not make a note of. and he should have. it's a very critical and important part of this. and so i would say,

mr. president, that although none of us like to see taxes increased, if at the end of the day we believe that our health insurance premiums were coming down, that more americans were going to have the peace of mind of health insurance, if they believe at the end of the day that they'll be more people insured and paying for more services, you can understand why the health care industry is participating in this conversation about this bill. as for the tax cuts, for those making $80,000 a year or less, i think it's a good idea. it's one of the biggest tax cut packages we've had. and we pay for it. this bill will generate a surplus in the treasury in the first ten years of $130 billion, in the second ten years of another $650 billion. it's the biggest deficit-reduction bill ever considered on the floor of the senate, according to the congressional budget office, and the republicans have nothing to offer which comes even close to that.

this is a rare sunday session. the rest of the day will be spent with speeches like this on the floor about this issue. but i can tell you we've never considered one more important. this is an issue which touches every american, every american family and every american business. we've worked long and hard to bring this to the floor. i know it's not perfect. no bill ever is. but it is a good-faith effort had a has gone through the scrutiny of the congressional budget office. for the critics on the other side -- and there are many -- my first question to each and every one of them: where is your comprehensive health care reform plan? where is a plan that is that has gone through the scrutiny and review that this plan has gone through? and the answer is: it doesn't exist. so i welcome their critiques, but i understand it is a critique without an alternative. i yield the floor. a senator: mr. president? the presiding officer: the senator from rhode island. mr. whitehouse: mr. president, may i ask unanimous consent that the distinguished senator from iowa be recognized for 20

minutes and that i be recognized following the conclusion of his remarks also for up to 20 minutes. the presiding officer: is there objection? without objection, so ordered. mr. whitehouse: i thank the chair and yield the floor. the presiding officer: the senator from iowa. mr. grassley: mr. president, the senator from illinois is still on the floor. last week i pointed out the plans that republicans have introduced right here. the only way that the senator from illinois can have an out is he was cute -- he was cute in modifying it that it hasn't been scored by the congressional budget office, but here's the fact on what the congressional budget office can do and not do. they were busy since may with the senate health bill, getting it scored. they were busy working with us in the group of six to try to get a bipartisan bill scored. and since october 2 until now,

they have been working with the senate leader full time to score thaefrg they have had a chance to put -- everything that they have had a chance to put oufplt oufplt -- put out. so i don't want anybody to think that republicans don't have alternatives to what's being offered here, but all he can say is they don't have a plan that's been scored. but we have plans, and if they want to hire more help in the congressional budget office, we'll get them scored. mr. president, i rise for the sake of 50 states in the united states today because in this 2,074-page bill is a massive budget burden for every one of the 50 states, or maybe i better say for almost all of the 50 states because of the expansion of medicaid. i'm talking about medicaid, a federal-state program.

i'm not talking about medicare, a totally federal program. if this bill becomes law, the congressional budget office estimates that by the year 2019, 54 million nonelderly, nondisabled americans will be locked in to medicaid. now there's a very important word i want to emphasize: "locked." because if these additional people in medicaid, they will not have any choice -- medicaid's the only place to get their health, where a lot of other people will have choices under what we call the exchange. so let me say it another way. i say they're locked in because this bill doesn't allow americans with incomes below 133% of the federal poverty level to get tax credits like

most other americans that aren't below 133% of poverty and a subsidy that comes through the exchange. 54 million americans will be locked in to a program -- and this is where we get back to the states -- that the 50 states cannot afford. we're not being honest with ourselves or our constituents or the people that will depend on the safety net if we try to argue that states can fund their share of this massive expansion. medicaid, as i said, is a federal-state partnership. probably about 43 years old. the federal government pays for, on average, 57% of the cost of medicaid. so on average, states pay about 43% of the program, and the

states administer the program. in my state of iowa, that division would be about 68% coming from the federal government, 32% that the taxpayers of iowa pay for. to describe medicaid's financial situation as fragile would be an understatement. earlier this year congress voted to provide states an additional $87 billion to states to prevent states from drastically cutting back their program. that's $87 billion out of the $787 billion stimulus bill. when we were considering that bill, the government accountability office made it clear to us that states were in crisis. every day you read about states being in crisis. budget crisis. the government accountability

office models predicted that state spending will grow faster than state revenues for at least the next ten years. so here is a warning that the government accountability office has provided to those of us in congress. quote -- quote -- "since most state and federal budgets are required to balance their budgets, the simulation suggests that without intervention, these governments would need to make substantial policy changes to avoid growing fiscal imbalances." end of quote from the government accountability office. mr. president, the state fiscal situation has not improved in the months since government ability office report. now let's go to the national governors association. they published a report recently entitled "the state fiscal situation: the lost decade." in this report, the nation's

governors portrayed a bleak picture of state finances. their report highlights the situation with state revenues and the economic situation. their report notes -- quote -- "the recent economic downturn starting in december 2007 and likely ending in august or september of 2009, making it one of the deepest and longest since the great depression." end of quote. state revenues are not likely to rebound until the years 2014 or 2015. states will continue to have to finance retiree spent pensions as they wait for this rebound. the national governors association conclusion is obviously a somber one. their report goes on to say, quoting again, "the government

line is that states will continue" -- i said the government line. "the bottom line is that states will continue to struggling over the next decade because of a combination of the length and depth of economic downturn and the projected slow recovery, even after states begin to see the light, they will face the overhang of unmet needs accumulating during the downturn," meaning the recent recession. end of quote. the report continues, still quoting, "the fact is that the biggest impact on states is the one to two years after the recession is over. the state having pwerd the recession in 2008, revenue shortfalls persisted into 2014 and the need to backfill deferred investments into core state functions. it will take states nearly a decade to fully emerge from the

current recession. end of quote from the governors. now here we have the national association of state budget officers from a december 2009 fiscal report about the terrible position that states are in right now, even without loading them down with the additional burden that's going to come through medicaid expansion in this 2,074-page bill. quoting from the national association of state budget officers, "states are currently facing one of the worst, if not the worst, fiscal periods since the great depression." and you see that quote behind me. under the current conditions, states will face significant challenges if they're to meet their current medicaid obligations. emphasis upon current without the addition of these millions

of people being put on medicaid because of expansion in this 2,074-page bill. states are also going to have to make a substantial policy changes to meet their budget obligations just currently the way it is -- the situation is. will state cut their medicaid programs to cut cost? right now as a condition of the $87 billion of the stimulus funds, states can't cut because that's a requirement of the stimulus package. under this bill, they won't be able to touch their medicaid programs until 2014, the year that they're forced into massively expand their programs. so what will states do to make their budgets work? will they cut roads and bridges? will they cut education? will they cut back on law enforcement and prisons? will the states raise taxes?

i can't say what 50 different states will do for certain, but states are going to have to make significant changes. right now in my state of iowa, my democratic governor culver is trying as best he can to work out a $565 million hole of which he has spending cuts in state government. that is intended to address the shortfall in the current budget year. a shortfall of more than $1 billion is forecast in my state for the budget year that begins july 1 next year. that's a major problem for our state legislators meeting in january. now, this isn't just iowa. 43 states have forced -- have been forced to cut spending in 2009. and it's not just about the raw numbers. it's about the people served by the program.

a few days ago aid group of constituents in my -- a few days ago i had a group of constituents in my office asking about a children's mental health program. they told heart-wrenching stories about providing care for their children. they recounted the struggles they have faced. they benefit from a combined federal-state program to provide them critical support services that aren't covered in medicaid. the state dollars that go into that program are going to be severely jeopardized when this bill takes effect and the states are going to have to assume a larger share because of our forcing them to expand medicare coverage. it's going to hurt these children i just referred to. right now iowa is looking at the possibility of closing two state mental health facilities.

in fact, "the des moines register" just recently editorialized that out of four, we ought to only keep one open. on december the 4th, iowa state courts were closed as workers there were furloughed without pay in an effort to close the budget gap. states are struggling to keep up essential services, and senators here will add a giant new unfunded mandate to states and hide behind the rhetoric of state responsibility. it is very disappointing to have people who claim to be champions of the poor and the needy turn a blind eye to the obvious impact of their actions in this bill on state budgets. and on the people served by those states. yet in the face of the evidence, the democrats are proposing a bill that forces states to expand their medicaid programs. this bill proposes that every state cover every american up to 133% of poverty. this is a massive expansion of

the welfare state. it is the largest expansion of medicaid in the 43-year history of the program. it will add another 15 million people to the medicaid rolls. it'll increase federal medicaid spending by $374 billion. it also will increase state spending by $25 billion. now, what states will be affected. every state -- every state here that's colored in red on this chart will be affected by this mandate. states are in their most dire fiscal situation since the great depression, and the democrats want to slip -- slap all of these states in red with a huge unfunded mandate. the majority obviously believes medicaid expansion is the right way to increase coverage.

the majority is willfully ignoring facts. states already can't afford the programs. and this bill requires states to spend on programs and make them pay more -- pay more for the privilege of doing so. and that's not the only cost being shifted to states. the insurer tax in this bill hits medicaid-managed care plans. those managed-care plans run on an extremely narrow margin. the tax on them is simply going to be passed on to the states. the decision made in the back rooms of the majority leader's office to keep all of the additional medicaid drug rebate dollars for the federal government will hurt states. i know some people will try to argue that you can't take something from the states that they never had, but for years states have been negotiating supplemental rebates with drug

companies. those will most certainly go away. and more and more people get added to the safety net. that safety net will not be able to hold up. that safety net is going to fall apart. this is a bill that will crash the safety net. if this bill is signed into law, it is only a matter of time before congress is forced to come back and restructure the policies in this bill and spend tens of billions of dollars more to keep the safety net from failing. failing failing completely. providing extra extra dollars to the state is going to become an annual right in the congress. it will very quickly become the so-called doctors' fix or the s.g.r. problem of medicaid. the governors know this as well, and i'd like to quote some. i'll start with the nevada governor, jim gibbons. "under the reid plan, a

mandatory expansion of the nevada medicaid program would add more than 41,000 people to the program's rolls in 2014. expanding nevada's medicaid enrollment by nearly 60% by 2019. overall, the reid plan will cost nevada taxpayers more than $613 million in state general fund dollars between 2014 and 2019. in addition to imposing this massive tax burden, the bill also removes existing state options essentially federalizing this program." end of quote from the governor of nevada. then a quote from north dakota's governor. "we along with the national governors' association urge extreme caution in moving forward with any plan that would commit the states without their expressed participation and consent to obligates that may financially bind them for

decades into the future." end of quote. i'll close with two of my favorite governors' quotesment both of these are democrats. the governor of tennessee says this: "there won't be new prisons built during that period, there won't be much in the way of capital improvements in the state during that period, so it's very scary for governors to be saying as soon as the revenues get back there, the federal government is going to come in and say 'here's how you're going to spend your new money'." and governor brian schweitzer, montana, says, "one of the least effective programs in terms of health care --" he is describing medicaid. "one of the least effective programs in terms of health care in the history of this country is something called medicaid. about 20% of america is on a medicaid program, and they would like to shift it and grow it to

somewhere around 25% or 30%." and a quote from governor schweitzer goes on, "now the medicaid program is a system that isn't working. almost everyone agrees. but what congress intends to do is increase the number of people on medicaid so that they could do it for the cheap. it's not working for anyone." "the democrats in congress are committing well more than $1 trillion of taxpayers' dollars to health care refomplet it is not our money. it's the taxpayers' money. it is our responsibility to make sure it is spent wisely. in medicaid, with massive expansion and a de facto tax increase on the states, this is clearly not the case." in other words, the money is not spent wisely. how much time do i have left? the presiding officer: you have a minute and a half. mr. grassley: in a minute and a half, i'd just simpliably simo

all the members of the senate's attention that tbee between nowd december 31 of this year, besides working on the health care bill, the debt ceiling has to be increased, we have got to pass a defense appropriations bill, we have got to decide what's going to happen with the death tax, the estate tax is going to -- at the end of this year, next year, there's not going to be any estate tax. i don't think anybody wants that situation to happen because it's only going to happen for one year. so we need to do something on estate tax. the highway bill needs to be reauthorized or extended. the patriot act has to be extended, because at least three parts of it expire, and if they are not reinstituted, a lot of the work of the f.b.i. tracking terrorists is going to be impossible. we got several tax provisions --

73 to be exact -- that are extended from time to time. they need to be extended. doctors are going to take a 23% cut in their reimbursement under medicare if we don't do something about it. the federal aviation administration needs to be reauthorized and maybe a satellite home viewers act needs to be reauthorized. all between now and the end of the year. this bill doesn't take effect until 2014, so we ought to be getting off of this health care bill and get some of these things that need to be done before the end of the year. i yield the floor. mr. whitehouse: mr. president? the presiding officer: the senator from rhode island is recognized. mr. whitehouse: mr. president, it appears to be just the two of us here, so if the senator from iowa would like to take a few more minutes to conclude his remarks, i have no objection. mr. grassley: thank you for your kindness. mr. whitehouse: very well. mr. president, i have had the

chance to -- i had the chance to sit yesterday where you are sitting today and had the chance to hear several hours of republican criticism of the health care bill, much of it focusing on the recent report from the c.m.s. office of the actuary. and the concern about cost -- and i'd like to come and say a few words about that. clearly, the problem of cost is a very, very real and dramatic one. this is the curve of our national health spending. starting back in 1955, the year i was born, at $12 billion -- $12 billion -- and increasing at an accelerating rate --

increasing at an accelerating rate -- until in 2009 we were at $2.5 trillion every single year. and, of course, if you look at the curve, we're not going to level out next year at that level. it's going to keep rocketing upward to the point where in my home state of rhode island, if we don't do anything, by 2016, which is just over the horizon -- that's not too far to look forward to, even in this building -- $26,000 is what 28 s what it'll cost the average family of four for their health insurance. $26,000. society problem of cost is a very real one and the numbers -- so the problem of cost is a very real one and the numbers involved is very staggering. but if you're going to look at the c.m.s. report, i would suggest that there is not just one number to look at. there are steferl numbers, and

then -- there are several numbers, and then there's an alternative consideration that i think we need to hold. the republicans have focused on page four of the c.m.s. report, where the actuary estimates that total national health expenditures under this bill would increase by an estimated total of $234 billion, or 0.7%, during the calendar years 2010 to 2019, over those ten years. and that is an important number, i will grant them that. but i think there is another number that is equally important, indeed more important. and that's the page before, on page three, where the c.m.s. actuary says that under this legislation, an additional 33

million people would become insured by 2019. an additional 33 million americans would become insured by 2019. think about that. we have over and over again come to the floor and told of stories from our home states, heard our colleagues tell of stories from their home states about the terrible toll and tragedy that befalls families when they are uninsured or underinsured. just 30 years ago we were about here. only 8% of american families filing for bankruptcy protection did so as a result of medical bills.

now it's 60%. 60% of family bankruptcies relate back to medical emergencies, unforeseen dying niece sees, medical bills -- unforeseen dying niece sis and medical bills that have broken the family. 33 million people with adequate health insurance so that don't face that trauma and catastrophe. that's something real. its a been estimated that because of a lack of -- it's been estimated that because of a lack of insurance 43,000 people a year die prematurely. 40,000 americans dead as a consequence of lack of insurance. so this bill would cover 33 million people and lift that burden of worry, of anxiety, of financial catastrophe, of worsened illness, even of death off of all of those families. that's not something to shrug off. and yet not once did i hear that

number mentioned by the other side, not once. not once did they even mention that this bill would cover 33 million americans who'd otherwise be without health insurance. they must hear the same stories at home. it's not that in republican states, there is no tragedy. they just come to this floor and don't bother to count that side of the equation. another number out of the report is that if you took just the savings side, the net savings from the medicare, medicaid, growth trend and class proposals in the bill are estimated to total about $564 billion -- net savings totaling $564 billion before you get to those 33 million. and then when you cover them, that's how it gets to

$24 billion -- $234 billion. so if you do rough math -- i'm not a great mathematician -- but if you have 33 million americans and they start getting coverage let's say five years out so that there's five years of coverage in this for them, and you divide it by $234 billion, it's about 1500 bucks -- 1500 bucks, per person, per year, to have those 33 million people insured. anybody who thinks for one minute about the human side of our health care tragedy cannot help but think that that would be a wise investment, for $1,500 to give somebody the security of health insurance? and, of course, that assumes that this bill actually does, when it's implemented, raise costs by $234 billion. but as somebody used to say on the radio, that's not the end of

the story. the end of the story takes a little bit of development, but i'd start by noting that the actuary himself says that the actual future impacts of this act on health expenditures, insured status, individual decisions and employer behavior are -- and i quote -- "very uncertain." why? because few precedents exist for use in estimation. consequently -- this is a quote -- "the estimation estimae presented here are held to a substantial uncertainty than is usually the case with more routine health care proposals." and in the conclusion, the c.m.s. actuary reiterates that. "these findings are subject to much greater uncertainty than normal. many of the provisions," they go on to say, "are unprecedented or have been implemented only on a

smaller scale. consequently, little historical experience is available with which to estimate the potential impacts." now, where does that affect the bill? where does that affect the bill? it doesn't affect it in new coverage. we know how much it costs to cover people. it doesn't affect it with expanding access to health care. we know how much that costs. where it affects it is on the savings side. it affects it on the savings side. and it's not just the c.m.s. actuary who says that. as i'll get to in a moment, that is also the conclusion of the congressional budget office. they agree on this. if we are going to get something done about this health care increase, we're going to have to do something about reforming the delivery system, about taking out waste and excess cost. those things are, by definition,

hard to predict. they don't lend themselves to the actuarial prediction that the c.m.s. actuary does and that c.b.o. does. but there's a big, big target out there. here's president obama's council of economic advisors. they had a report out in june -- sorry, july. "efficiency improvements in the u.s. health care system potentially could free up resources equal to 5% of u.s. g.d.p." "it should be possible to cut total health expenditures by about 30% without worsening outcomes, which would again suggest that savings on the order of 5% of g.d.p. could be feasible." 5% of g.d.p. is about $700 billion a year. so there's a big savings target

to do something about those national health expenditures. and some groups, like the lewen group, who've looked at this pretty hard, have come up with some pretty good ideas whereof those saving could be find -- where those savings could be found. they don't project it at $700 billion a year in excess waste and costs. they predict that it's over a trillion dollars a year that we now burn up in our system through excess services, waste, and excess cost. and they've actually broken out where you can go to find it. excess costs due to transactional inefficiencies, all that excess billing and paperwork. excess costs due to competition and regulatory factors. they don't compete. you get a couple big insurance companies in there. they take over. they're not subject to the antitrust laws. they make deals with each other, with the hospitals. of course the regular person is on a short end of that deal. excess costs from poor care management and lifestyle factors. well, we know care management is terrible. there's very poor coordination

of care. and lifestyle factors, we are investing in wellness and prevention to address those in this bill. excess costs from incentives to overuse services. when you pay doctors for doing stuff, that's what they do. when you pay them for health care outcomes, you'll get better health care outcomes and you'll get them cheaper. so this adds up to over a trillion dollars in excess costs that is our target. that's a real number. it's a big number. and there is a problem with how you get after the savings. a lot of people actually agree on this and so i'd like to pull a couple of sources together. we heard already from the c.m.s. actuary who said that some of this is unprecedented and there aren't historical records to exactly extrapolate how it's going to work. here's what the -- doug elmendorf, the head of c.b.o., has said. "changes many government policy have the potential -- changes in government policy have the potential to yield large reductions in both

national health expenditures and federal health care spending without harming health. many experts agree on some general directions in which the government's health policy should move. many of the specific changes that might ultimately prove most important" -- "specific chaipgz that mighchangesthat might ultit important cannot be foreseen today and could only be developed over time through experimentation and learning." so there's the potential for large reductions in costs. we agree on the general directions that need to be pursued to achieve those large reductions, but experimentation and learning are going to be necessary to do it. well, there's a professor jonathan gruber, who's probably the lead health economist -- one of the leading health economists in the world, the lead health economist at the massachusetts institute of technology. he took a look at this book -- at this bill and he said this,

"my summary is it's really hard to figure out how to bend the cost curve, but i can't think of a thing to try that they didn't try that's in our bill." "i can't think of a thing to try that they didn't try. they really make the best effort anyone has ever made. everything is in here. i can't think of anything i'd do that they are not doing in the bill. you couldn't have done better than they are doing." $700 billion to a $1 trillion target. hard to project with t it, whetr you're c.b.o. or c.m.s. but we know the general directions that are required, and we have everything in this bill that we can to explore it. somebody's actually taken a bit of a look at this. they focused hard and they admit that their findings aren't as

solid as, you know, a full actuarial report. but the commonwealth fund does a lot of work in this area and they're very good people. and here's what they conclude. "the effect of national reform on total national health expenditures and the insurance premiums that family would likely pay is this. we would save $683 billion or more in national health spending over the ten-year period 2010-2019." $683 billion. and where do they go for that? to things like administrative expense. remember, i pointed out the problem of administrative expense and transactional inefficiencies? currently, nearly 13% of insurance 3r50e78 yums -- insurance premiums are accounted for by administrative costs. things that we do in this bill

can reduce that. they say -- they make a very modest estimate, that administrative costs will fall to 10% of total premiums. the reduction in health spending associated with reduced insurer administration is $191 billion to $221 billion over 2010-2019. that's just making the paperwork more efficient. and it's around a $200 billion savings. c.b.o. also estimates some reduction in premiums from exchanges. if you take the c.b.o. estimates, and they apply them here, they say that those estimates from the exchanges yield ten-year savings of $29 billion to $34 billion. then they look at the delivery system innovations, payment innovations, so you're paying for outcomes, not procedures, negotiation of pharmaceutical prices, because you know our friends across the aisle made the pharmaceutical industry immune from negotiation by the federal government in their last piece of legislation, part-d.

comparative effectiveness study, so you know whether something works or not before you pay for it. financial incentives for low-quality and high-cost providers to improve and get their act together. wellness and prevention investment. demonstration and pilot projects in medicare to pull these things together. and the ongoing medicare commission that our colleague, senator rockefeller, is such a champion of, as well as the excise tax on the high-cost insurance plans. the exact amount that would be saved from these provisions collectively is uncertain, the report admits, but they look at some scholarly estimates. one scholarly report estimates that significant health care reform could reduce cost increases by 1.5 percentage points annually or more than $700 billion in the ten-year window. another scholarly report estimates that savings of more than 10% are possible, largely from payment reforms like bundled payment system. a commonwealth fund report indicates that similar provisions would slow the annual

growth in national health expenditures from 6.5% to 5.6% over the period 2010-2020. so cost reductions on the order of 1.0 percentage points are realistic. to be conservative. they considered cost savings of a smaller amount, .75%. and they concluded that the public and private savings from health system modernization are $530 billion over the ten years. taking account of these different factors, they say, on net, the senate bill should reduce health care spending by $683 billion over 2010-2019. now, why is that? we have another very thoughtful observer of the health care scene who has offered some opinions on this. hothat is dr. atul gawande. he's written several times in

the "new yorker" on this subject. he notes that "it appears that the legislation news master plan for dealing with the problem of soaring medical costs." he says, "we crave sweeping transformation. however, all the current bill offers is those pilot programs, a battery of small-scale experiments. the strategy," he says, "seems hopelessly inadequate to solve a problem of this magnitude." and yet," he concludes -- and i quote, here's the interesting thing -- "history suggests otherwise." and he uses the example of -- and i quote -- "another indispensable but unmanageablely costly sector that was strung ling the country at the -- strangling the county at the beginning of the 20th century and that was agriculture." he says, "the government never took over agriculture but the government didn't leave it alone either. it shaped a feedback loop of experiment and learning and encouragement for farmers across the country." experiment and learning? does that sound at all like the c.b.o. words?

"the results were beyond what anyone could have imagined. productivity went way up, prices fell by half. today, sphoo food is produced oo more land than was devoted to it a century ago and with far greater variety and abundance than ever before in history. the strategy worked," he concludes, "because united states agencies were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against social goals." the same goes for reforming the health care system, he says. nobody found a master switch that you can flip to make that delivery system cost problem go away. we first need to recognize that there is no technical solution. but much like farming, hospitals, clinics, pharmaceuticals, home health

agencies, drug and device sphraoeurbgs he says, want to provide good care but they also measure their success by the amount of revenue they take in and as each pursues its individual interests, the net result is disastrous. the system, he says, rewards doing more over doing right. it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. let's dashes may i have an additional -- let's -- may i have an additional five minutes. the presiding officer: without objection, so ordered. mr. whitehouse: dr. kwan day continues pick up the senate health care bill. just like professor gruber said, i don't think of a thing to try that they didn't try. they really make the best effort

anyone has ever made. everything is in here. i can't think of anything i'd do that they're not doing in the bill. you couldn't have done better than they are doing. the bill is a hodgepodge, gawande continues, and it should be. which of these programs will work, he asks? we can't know. that's why the congressional budget office doesn't credit any of them with substantial savings. but we should not lose faith. he concludes, "there's no piece of legislation that will have all the answers but if we're willing to accept a messy, continuous process we can come to grips with problems even of this immensity. we have done it before." so when the other side comes to the table and argues that this bill is a cost disaster and a nightmare and all the things they're saying, i would urge people to consider two things. the first is that they have been pretty clear that they don't

want a bill at all ever. any bill. none. their desire to deny our new president this victory is an you ulterior goal that they have declared. senators have said that they want it to be his waterloo. they said it's our goal to break him, to break his momentum. so when they say start over, it's a little hard to believe it. if they were candid, they'd say no, stop dead and leave it things as they are. but america wouldn't get behind that, so they have started with this "start over" theory. when you look at what their political purpose is -- to break president obama, to stop his momentum -- it's worth considering their protestations on the floor in that light. the other light it is worth considering them in is this one

if we're going to save significant money by making the delivery system more efficient, all these experts agree you can't cost it out in advance. the twaeurs can't figure it -- the actuaries can't figure it out. but the tools we need to make it happen aren't in there. the intent of the obama administration to make it happen is in there. the savings target is between $700 billion and over $1 trillion a year. and when we achieve those savings, we're improving the quality of health care. it's less duplicative, less wasteful, less paperwork, the quality goes up. the perfect example is the famous keystone project in michigan where they practically eliminated hospital-acquired infections in intensive care units in a number of hospitals in michigan. in 15 months, they saved 1,500 lives and $150 million. when they started that, could an actuary have predicted that that would happen? no. never.

never. at the beginning of the agricultural revolution and we modernized the american agricultural sector, could you have predicted what dr. gawande reported? no, you cannot. you cannot predict it but this president can direct it. he can make it happen. we will give him the tools. for those that are concerned about cost, there is very significant grounds for optimism about what will happen in this bill. if we don't do it this way with those delivery system reforms, we're going to be left with a bloody toolbox. cutting people off, throwing them out, chopping the benefits, paying providers less. it will be to health care reform what a civil war surgeon's toolbox was to modern medicines. saws, knives, kau terring -- cautering irons and patients screaming t. doesn't have to be that way. there is a better way, and it is in the bill.

i thank the distinguished senator for yielding me the extra time, and i yield the floor. a senator: mr. president? the presiding officer: the senator from north carolina is recognized. mr. burr: mr. president, i ask unanimous consent to speak for 20 minutes. without objection, so ordered. mr. burr: mr. president, as my colleague finished up, he made the statement when the other side comes to the table. let me just say at the beginning of this, we've been asking to be invited to the table since the beginning of this debate. unfortunately, we don't know where the table is. we've never been invited. and we hope before this is over, we'll have an opportunity to provide input into a health care bill that affects 300 million americans. but on this rare session, as i've heard it described, of a sunday session of the united states senate, where i know the

president of the senate has sat in the chair for quite awhile now, i'm reminded of one of our colleagues -- the senator from oklahoma -- the doctor, tom coburn, whose mother passed away on sunday. sometime this weekend there is a service, and i know that my colleagues join me in saying to tom, "our hearts and our prayers go out to you and to your family." my mother died in between the time i was elected to the united states senate but before i was actually sworn in. she was able to live to see me win but not -- she didn't live to see me sworn in to the united states senate. and i know how traumatic the loss of a parent can be. but i remember in my case how quickly you focus on the fact that mothers have an incredible gift given to them by god.

the gift of birthing children, of replenishing the next generation, and how quickly i remember my focus shifted from the loss of my mother to the responsibility of my children. because i think as parents, we had undervalued that. and that was a shock to me, to make me wake up and say, i have a responsibility now to make sure that i nurture, to make sure that i raise, to make sure that i educate fell on my wife's and my shoulders, because that was the next generation of business. that was and will be the next generation of leaders locally, the state level, and nationally. parents are invaluable, but so are the kids they produce.

and the opportunity from there on generationally to experience what's great about this country -- and that's unlimited opportunity. and my responsibility is not just to nurture and to raise two sons, in my case, or in tom's case great daughters, and one's a tremendous opera singer, probably the most sought-after in the world, but it's also to make sure that we protect the opportunities that we're given, to make sure that what people have fought for in wars before are recognized to preserve the opportunity of success. well, i feel like in our position today that's part of our responsibility. we're here to preserve the opportunity for the generations, for pages, for children, for our own kids. so it does hurt on a rare sunday

session to have come in to one of the most difficult economic crisis periods in our country's history and watch without much thought as the united states senate passed a spending bill that had a 12% increase from last year, something no family can do right now, something that no individual can do. we borrowed 43 cents of every dollar that we just spent in that bill, and there's no family in the world that can go into the bank and say, "i'd like to borrow 43 cents of the dollars that i'd like to go out and buy this big-screen tv. i don't need it but i won't it." there's some things in this bill that we need, but there's a lot in this bill that we just want. over 5,000 earmarks. members of congress actually, at a time that we should be

prioritizing our spending in this country, not only did we raise it 12% over last year, but we had the audacity to stick 5,244 earmarks in this bill because we can do that, because somebody asked us. and the truth is that families can't, communities can't, no states can't. they've got laws against it. they have to balance their budget. families have to balance their budget or they file bankruptcy. communities have to balance their budget and try to meet the core responsibilities of providing services to their community. and there's a choice when they do it. do we overtax a community through property taxes or do we prioritize what we spend our money on? we never prioritize in this

institution anymore. we believe we can spend as much as we possibly want to. that's evidenced by 5,244 earmarks. the fact that we just spent $3.9 billion that wasn't even in the bill originally when the appropriators received their caps. well, i'm sure that the community needed their park. and i'm sure that the community needed the study or the service that each one of those 5,244 earmarks represent. but let me ask you this: if they need it that bad, couldn't this fund it themselves? say it again. if they needed it that bad, couldn't this fund it stph*epls why did earmarks -- why were they created? it's because it's a way to get somebody else to pay for something you want, not

necessarily you need. well, let me say, mr. president, to you, to my colleagues, to everybody listening, we're broke. we borrow 43 cents of every dollar we spend in the federal government right now. the ten-year projection says we're going to increase the debt more in the next ten years than we did in the first 43 presidents. what else do we need to hear to stop spending? but it just continues to roll on and roll on and roll on. and you know what? we're going to get another opportunity to do it next week, another opportunity to spend money we don't have. we're going to get an opportunity to raise the debt ceiling, something that for the 15 years that i've been here was a big debate. how much do we need? when do we do it? it was a tool that we used to force us to prioritize. we're going to stick a $1.8 trillion debt ceiling increase into a defense appropriations bill so that everybody feels guilty about voting against it

if they do -- and i will for the first time because i believe it's wrong. i believe it's wrong, and it shouldn't be done. well, mr. president, let me just say this. sometimes you have to say no. you know, as my children grew up, the toughest thing was to look at those kids and say "no." "i want this." "what do you want for christmas?" "i want this." "no." when i started work, i was always told in sales the toughest thing you're going to have to do is to say no. i'll buy it for you, but i'll only pay this much. no. well, we're at that point where the american people have said prioritize. we've got to look at communities.

we've got to look at states, and we've got to have guts enough to say no. you know. mr. president, wealth is not created by government. wealth is not created by states. the government steals wealth when the opportunity is available. communities will grow and they will be healthy and states will grow and they will be healthy, but only through local success. it does not come through handouts from the federal government. all that does is give us a false sense of security and a false sense of a bank account. in the midst of all this, as a we've pass -- as we've passed this huge spending bill -- $12% increase -- we're -- 12%

increase, we are a glai debating health care. we are a debating a health care bill that steals $464 billion from medicare. i just talked about the transition i went through from the loss of a parent to the focus of children and now all of a sudden i'm stealing from my parents. as an institution, we're getting ready to steal $464 billion from medicare. and people up here don't seem worried about it. and my dad and possibly your dad and your mother have been paying into it their entire life and promised that it would always be there. let me give you a little secret today. medicare is underfunded by $34 trillion. that's with a "t." the most popular bumper sticker in washington today is "don't

tell congress what comes after a trillion." $34 trillion. it is not a guess by an actuary. that's real number. the medicare board says that it's insolvent in 2017, eight years from now. what are we doing? we're stealing $464 billion out of it. i've heard people come to the floor and say, they'll never miss it. it won't affect a benefit. it won't affect a service. it won't affect a facility, a hospital. and now all of a sudden over this weekend, we've been presented with the news stories -- nobody has seen a bill, including many democrats uke, fm the majority leader, that suggests that they may have a deal that expands medicare to

include the 5 to 64-year-old age group. potentially 20-plus million people. i've heard people say, that's only going to be 2 million. so i guess it's going to be crafted in a way that leaves some out and let's som out and . maybe somehow this is going to be crafted in way that we let 2 million 55-to 64-year-olds in and leaves the others out. my good friend from rhode island talked about the c.m.s. act weared and what he had to say. i wasn't prepared to come today and read every editorial out of the washington street journal, but had i, think it would have rebutted most of m what my colleague said. let me read a couple of quotes from the act washings the same one that senator white house talked about. it said, "the reid bill is

especially likely to result in providers being unwilling to treat medicare and medicaid patients." unwilling to treat medicare and medicaid patients. in other words, not stealing the $464 billion. well, yeah, stealing the $464 billion is going to generate less interest by providers to see patients. well, there's only 60% of the doctors today seeing medicaid patients. there's about 74% seeing medicare patients. all of a sudden, you like your health insurance, you can keep your doctor, you can keep your plan. that's out the window according to the c.m.s. actuary. the actuary noted that the cuts in the bill would jeopardize

access to care. it's the president's person. medicare cuts in the bill could jeopardize medicare beneficiaries' access to care. he also found that roughly 20% of part-a providers -- that's hospitals and nursing homes, two things additionally we cut, specifically we cut, hospitals and nursing homes -- would become unprofitable within the next ten years as a result of these cuts. well, my take is as a businessman, not a lawyer, a when an entity is unprofitable, they go out of business. when there's not enough revenue to meet your expenses, you close your door. so in essence what the c.m.s. actuary noted in this was that hospitals and nursing homes would shut, their doors would

close. that's why senator conrad and others and me who represent rural parts of the country have tried to say to my colleagues, pass this bill and you eliminate rural hospitals. you eliminate the ability to provide preventive care in rural america. when a woman in rural america gets pregnant, there won't be prenatal care there. she'll have to drive 60 miles to get the prenatal care she needs, and they will she'll never do that. but she will drive 60 miles to deliver that baby, that will end up in the n.i.c. unit, and we will spend hundreds of thousands of dollars to treat that baby when we could have kept that local facility open and provided the level of preventive care that she needed. but, no, in this, it says 20% --

20% of our country's hospitals and nursing homes will close if we pass the reid bill. it also says -- the actuary found that further reductions in medicare growth rates through the actions of the independent medicare advisory board -- now, this is important because this is what they always point to. well, the medicare advisory board is going to do this. it says, "medicare advisory board which advocates have pointed to as a central linchpin in reducing health care spending quote 'may be difficult to achieve in practice'." layman's terms, they ain't going to do it. so, independent medicare advisory board, c.m.s. actuary says not going to happen. geez, how can we take the same actuary's report and get such a

different view of what the results of this bill are between me and the last speaker? the actuary says, the reid bill would cul cut payments to medice advantage plans by approximately $110 billion over ten years resulting in less generous benefit packages and decreasing enrollment in medicare advantage plans by 33%. like your insurance, get to keep it. nope. like your doctor, get to keep him. nope. like your hospital, get to keep it. not if it closes. like your nursing home, get to keep it. no. the actuary says, 20% of them are going to go out of business. they won't be in business. as a matter of fact, the reid bill funds $930 billion in new federal spending by relying on medicare cuts.

as a result, the actuary says, providers could find it difficult to remain profitable and absent legislative intervention might end their participation in the medicare program, possibly jeopardizing access to care for beneficiaries. wooo, boy. now we've eliminated the hospital. we've eliminated the nursing home. we've eliminated medicare advantage. now the actuary says, the doctors, because of what we're doing, may opt out of the system. mr. president, the majority whip came to the floor earlier and he said, the republicans won't offer a plan. for the record and for the 100th time, tom coburn and i introduced comprehensive health care legislation in may. we were the first members of congress, house or senate to introduce comprehensive health

care legislation. i'm not sure how many times i can come to the floor and say that. tom and tom and i came down and spoke for hours. it's got some good things in it. we'd love to have some input into whatever the legislation is going to do. but make no mistake about it. just because you stick your head in a hole and see nothing else out there doesn't mean it is not there. to come to the floor and claim that no republicans have offered a legislative remedy to health care is to stick your head in a hole and say, i'm not going it look. therefore, nothing exists. now, mr. president, i know i'm coming to the end, and i see that the ranking member of the finance committee wants to speak. my good friend from rhode island said -- and i quote -- i wrote

it -- "actuaries can't cost it out." he said before he left the floor, "actuaries can't cost it out." well, he may or may not be right. i can tell you this: the american people can cost it out, and the american people have said "no." "no" to passage of the reid health care bill. we should listen to the american people. mr. president, i yield the floor.

mr. grassley: mr. president? the presiding officer: the senator from iowa is recognized. mr. grassley: we keep hearing about all the tax cuts that are in this 2,074-page bill. earlier today i heard the distinguished senator -- senior senator from illinois say this, after senator kyl was done speaking: first -- and i am

reading from the transcript -- "first, this bill has $441 billion in tax cuts in the first ten years. for average people trying to pay their health insurance premiums, i don't know if the senator from oz oz, senator kyl, thinks that's a good idea for not. hay never spoken to that. at least i haven't heard it. i think it is a good idea if you're making less than $80,000 a year, i won't's want to make sure you have insurance and it bill wants to make sure we give you a helping hand. it is a tax cut." first of all, when you have a tax credit or subsidy for buying insurance, the joint committee often taxation -- the joint committee on taxation describes 70% of that as outlays, 27% as tax reductions.

so, to call $441 billion a tax cut is completely contrary to the way scorekeepers or the congress keep track of things. the second thing is that i noticed in talking about helping people $80,000 a year or so -- and i heard another senator speak frankly about tax increases for people at $75,000 -- there seems to be an effort to define down what the middle class is from what the president of the united states described it in the last election. individuals under $200,000, families under $250,000 being middle class. well, i want to go into some detail about this because i've had an opportunity to speak on this point, and i think other members have