the presiding officer: the senator from montana. mr. baucus: reserving the right to object. i certainly agree with the basic underlying import that we should know what we're voting on here. i must say to my good friend from oklahoma, i cannot certify that members of the senate will understand what -- what they're reading. that presumes a certain level of -- of perception on my part and understanding in delving into the minds of the senator, that not only do they read, but take the time to understand? what does understand mean? understand the first, second levels of questions? i think it is impossible to certify that any senator fully understood. they hey read, but not fully understand for a variety of reasons. iú -- mr. coburn: i would clarify my request. that the individual certify themselves. i'm not asking some group of senators to certify some other senator.

i'm saying tom coburn tell his constituency i've read this puppy, i've spent the time on it, i've read the manager's amendment, and i, in fact, certify to the people of oklahoma, i know how terrible it's going to be for their health care. mr. baucus: the senator is always free to make any representation he wants. if he wants to certify he has read it, he has understood it, that's the senator's privilege. mr. coburn: the senator won't accept that we as a body on 1/6 of the economy ought to know what we're doing. mr. baucus: i can't certify any member of the senate has done anything around here. neither can the senator from oklahoma. if the senator wants to certify it, that's great. on any measure. but i can't certify on 100 different senators. that's up to the different senators. that's up to their mental capacities and consciences and so forth. i can't certify that.

mr. baucus: mr. president? the presiding officer: the senator from montana. mr. baucus: i have eight unanimous consent requests for committees to meet during today's session of the senate. they have the approval of the majority and minority leaders. i ask consent that these requests be agreed to and they be printed in the record. the presiding officer: without objection. mr. baucus: mr. president, i ask consent the senator from from vermont be recognized to proceed for at least a half-hour. the presiding officer: the senator from vermont. without objection. mr. sanders: mr. president, i call up my amendment per the order. the presiding officer: the clerk will report the amendment. the clerk: the senator from vermont, mr. sanders, for himself and others, proposes an amendment number 2837 to amendment number 2786. beginning on page 1, strike line 6, and all that follows to the end, and insert the following -- mr. sanders: i ask the amendment be considered as read. a senator: i object. the presiding officer: objection is heard.

the clerk:: b, table of contents. the table of contents of this act is as follows -- title 1, american health security. section 1000, short title. sub title a. establishment of a state-based american health security program, universal entitlement enrollment. section 1001, establishment of a state-based american health security program. section 1002, universal entitlement. section 1003, enrollment. section 1004, portability of benefits. section 1005, effective date of benefits. section 1006, relationship of existing federal health programs. sub title b, comprehensive benefits, including preventative benefits and benefits for long-term care. section 1101, comprehensive

benefits. section 1102, definitions relating to services. section 1103, special rules for home and community-based long-term care services. section 1104, exclusive and limitations. section 1105, certification, quality review, plans of care. sub title c. provider participation. section 1201. provider participation and standards. section 1202, equal if i indicatings for providers. section 1203, -- qualifications for comprehensive health service organizations. section 1204, limitation on certain physician referrals. sub title d, administration. part one, general administrative

provisions. section 1301, american health security standards board. section 1302, american health security advisory council. section 1303, consultation with private entities. section 1304, state health security programs. section 1305, complementary conduct of related program. part two, control over fraud and abuse. section 1310, application of federal saingz to all -- sanctions to all fraud and abuse under the american health security program. section 1311, requirements for operation of state health care fraud and abuse control units. sub title e, quality assessment. section 1401, american health security quality council. section 1402, development of certain mythologies, guidelines, and standards.

section 1403, state quality review programs. section 1404, elimination of utilization review programs transition. sub title f, health security budget. payments, cost containment measures. part 1, budgeting and payments to states. section 1501, national health security budget. section 1502, computation of individual and state capitation amounts. section 1503, state health security budgets. section 1504, federal payments to states. section 1505, account for health professionals education expenditures. part, payments by states to providers. section 1510, payments to hospitals and other facility-based services for operating expenses on the basis

of approved global budgets. section 1511, payments to health care practitioners based on prospect tiff fee schedule. section 1512, payments to comprehensive health service organizations. section 1513, payment for community-based primary health services. mr. sanders: i would ask that the amendment be considered as read so i can offer the amendments. the presiding officer: is there objection? a senator: there is objection. the presiding officer: objection is heard. mr. sanders: i ask my friend from oklahoma -- i ask may friend from oklahoma why he is objecting. mr. coburn: regular order, mr. president. the presiding officer: regular order is the reading of the amendment. the clerk: section 1514, payments for prescription drugs. section 1515, payments for approved devices and equipment. section 1516, payments for other items and services.

section 1517, payment incentives for medically underserved areas. section 1518, authority for alternative payment mythologies. part 3, mandatory assignment and administrative provisions. section 1520, mandatory assignment. section 1521, procedures for reimbursement appeals. sub title g. financing provisions american health security trust fund. section 1513, amendment of 1986 code, section 15 not to apply. part 1, american health security trust fund. section 1531, american health security trust fund. part 2, taxes based on income and wages. section 1534, payroll tax on employers. section 1536, health care income tax, sub title h. conforming amendments to the

employer retirement income security act of 1974. section 1601, erisa inapplicable to health coverage arrangements under state health security programs. section 1602, exemption of state health security programs from erisa preemption. section 1603, prohibition of employee benefits duplicative of benefits under state health security programs, coordination in case of workers compensation. section 1604, repeal of continuation coverage requirements under erisa and certain other requirements relating to group health plans. section 1605, effective date of sub title. sub title 1, additional conforming amendments. section 1701, repeal of certain provisions in internal revenue code of 1986. section 1702.

repeal of certain provisions in the plea retirement income security act of 1974. section 1703, repeal of certain provisions in the public health service act and related provisions. section 1704, effective date of sub title. title 2, health care quality improvements. section 2001, health care delivery system research, quality improvement, technical assistance. section 2002, establishing community health teams to support the patient-centered medical home. section 2003, medication management services and treatment of chronic disease. section 2004, design and implementation of regionalized systems for emergency care. section 2005, program to facilitate shared decisionmaking. section 2006, presentation of prescription drug benefit and risk information. section 2007, demonstration

program to integrate quality improvement in patient safety training into clinical education of health professionals. section 2008, improving women's health. section 2009, patient navigator program. section 2010, authorization of appropriations. title 3, prevention of chronic disease and improving public health. sub title a, modernizing disease prevention in public health systems. section 3001, national prevention, health promotion, and public health council. section 3002, prevention and public health fund. section 3003, clinical and community preventative services. section 3004, education and outreach campaign regarding preventative benefits. sub title b, increasing access to clinical preventative services. section 3101, school-based health centers. section 3102, oral health care prevention activities. sub title c, creating healthier

communities. section 3201, community transformation grants. section 3202, healthy aging, living well evaluation of community-based prevention and wellness programs. section 3203, removing barriers and improving access to wellness for individuals with disabilities. section 3204, immunizations. section 3205, nutrition labeling of standard menu items at chain restaurants. section 3206, demonstration project concerning individualized wellness plan. section 3207, reasonable break time for nursing mothers. sub title d, support for prevention and public health inovation. section 3301, research on optimizing the delivery of public health services. section 3302, understanding health disparities, data collection and analysis. section 3303, c.d.c. and employer-based wellness programs. section 3304, epidemiology,

laboratory capacity grants. section 3305, advancing research and treatment for pain care management. section 3306, funding for childhood obesity demonstration project. sub title e, miscellaneous provisions. section 3401, sense of the senate concerning c.b.o. scoring. section 3402, effectiveness of federal health wellness initiatives. title 4, health care work force, sub title a, purpose and definitions. section 4001, purpose. section 4002, definitions. sub title b, innovations in the health care work force. section 4101, national health care work force commission. section 4102. state health care work force development grants. section 4103, health care work force assessment. sub title c, increasing the supply of the health care work force. section 4201, federally supported student loan funds.

section 4202, nursing student loan program. section 4203, health care work force loan repayment programs. section 4204, public health work force improvement and retention programs. section 4205, allied health work force recruitment and retention programs. section 4206, grants for state and local programs. section 4207, funding for national health services corps. section 4208, nurse-managed health clinics. section 4209, elimination of cap on commission corps. section 4210, establishing a ready reserve corps. sub title d, enhancing health care work force education and training. section 4301, training and family medicine, general internal medicine, general pediatrics and physician stanceship. section 4302, training opportunities for direct care workers. section 4303, training in general pediatric and public health dentistry.

section 4304, alternative dental health care providers demonstration project. section 4305, geriatric education and training career awards, comprehensive geriatric education. section 4306, mental and behavioral health education and training grants. section 4307, cultural competency public health and individuals with disabilities training. section 4308, advance nursing education grants. section 4309, nurse education practice and retention grants. section 4310, lowe loma program. section 4312, authorization of appropriations for part-b through d of title 8. section 4313, grants to promote the community health workforce. section 43413, public health. section 4315, united states public health sciences track.

subtitle e, supporting the existing health care workforce. section 4401, centers of excellence. section 4402, health care professionals training for diversity. section 4403, interdisciplinary community-based linkages, section 4404, workforce diversity grants, section 4405, primary care extension program. subtitle f. strengthening primary care and other workforce improvements. section 4501, demonstration projects to address health professions workforce needs, extension of family-to-family health information centers. section 450 2k, increasing teaching capacity. section 4503, graduate nurse education demonstration. subtitle g, improving access to health care services. section 4601, spending for federally qualified health centers. section 4602, negotiated rule making for development of

methodology and criteria for designating medically underserved populations and health professions shortage areas. section 4603, reauthorization of the wakefield emergency medical services for children program. section 4604, colocating primary and specialty care in community-based men it will health settings. section 4605, key national indicator. subtitle h, general provisions. section 4701, reports. title 5, transparency in program integrity. title a,ification ownership and other transparency. section 5001, investment interests. section 5002, prescription drug sample transparency. subtitle b, nursing home transparency and improvements. part 1, improving transparency of information. section 5101, required

disclosure of ownership and additional disclosable parties information. section 5102, accountability requirements for skilled nursing facilities and nursing facilities. section 5104, standardized complaint form. section 5105, insuring staffing accountability. part 2, targeting enforcement. section 5111, civil money penalties, section 5112, national independent monitored demonstration project. section 5113, note anyquation of the facility closure. section 5114, national demonstration projects on cultural change and use of information technology in nursing homes. part 3, improving staff training. section 5121, dementia and abuse prevention training. subtitle c, nationwide program for national and state background checks on direct patient access, employees of long-term health care facilities and providers. section 5201, nationwide program

for national and state background checks on direct patient access employees of long-term care facilities and providers. subtitle d, patient-centered outcomes research. section 5301, patient-centered outcomes research. subtitle f, elder justice act. section 5402, definitions. section 5403, elder justice. subtitle g, sense of the senate regarding medical malpractice. section 5501, sense of the senate regarding medical malpractice. section -- title 6, improving access to innovative medical therapies. subtitle a, biologics price competition and innovation. section 6001, short title. section 6002, approval pathway for biosimilar products.

section 6003, savings. subtitle b, more affordable med disins for children in underserved communities. section 61001, expanded participation in 340-b program. section 6102, improvements to the program integrity. section 6103, g.a.o. study to make recommendations on improving the 340-b program. title 1, american health security. section 1000, short title. this title may be cited as the american health security act of 2009. subtitle a, establishment of the state-based american health security program, universal entitlement enrollment. section 1001, establishment of a state-based american health security program. a, in general, it is hereby established? the united states a state-based american health security program

to be administered by the individual states in accordance with federal standards specified in or established under this title. b, state health security programs. in order for a state to be eligible to receive payment under section 1504, the state must establish a state health security program in accordance with this title. c, state defined. 1, in general this this title, subject of paragraph 2, the term "state" means etch of the 50 states and the district of columbia. 2, election. if the governor of puerto rico, the virginia gin islands, guam, or the northern mariana islands certifies to the president that the legislature of the commonwealth or territory has enacted legislation desiring that the commonwealth or territory be included as a state under the provisions of this title, such commonwealth or territory shall be included as a state. under this title, beginning january 1 of the first year beginning 90 days after the president receives the notification. section 1002, universal

entitlement. a, in general, every individual who is a reserve dentes of the united states and is a citizen or national of the united states or lawful resident alien, as defined in subsection d is entitled to benefits for health care services under this title under the appropriate state health security program. in this program, the term "appropriate state health security program" means with respect to an individual the state health security program for the state in which the individual maintains a primary residence. b, treatment of certain nonimmigrants. one, in general, the american health security standards board in this title referred to as "the board" may make eligible for benefits under the health care services under the state program under this title such classes of aliens as nonimmigrants a the board may provide. two, consideration. in providing for eligibility under paragraph 1, the board shall consider reciprocity in health care services offered to

united states citizens who are nonimmigrant and other foreign states assed board determines to be appropriate. c, treatment of other individuals. one, by board. the board also may take eligible for benefits for health care services under the appropriate state health security program under this title other individuals not described in subsection a or b and regulate the nature of the eligibility of such individuals in order, a to preserve the public health of communities, b, to compensate states for the additional health care financing burdens created by such individuals and, c, to prevent adverse financial and medical consequences of u uncompensated care. while inhibiting travel and immigration to the united states for the sole purpose of obtaining health care services, two, sphwaits. any state health security program may make individuals described in paragraph one eligible for benefits at the expense of the state. d, lawful resident alien defined. for purposes of this serks the term "lawful resident alien"

mean an alien lawfully admitted for permanent residence and any other alien lawfully residing permanently in the united states under color of law including an alien with lawful temporary resident status under section 21012a of the immigration and nationality act, 8 yaws code 1160, 1161, or 125-a. section 1003, enroll many. a, in general, each state health security program shall provide a mechanism for the enrollment of individuals entitled or eligible for benefits under this title. the mechanism shall, one, include a process for the automatic enrollment of individuals at the time of birth in the united states and at the time of immigration into the united states or other acquisition of lawful resident statistic news the united states. two, provide for the enrollment as of january 12, 011 of all individuals eligible for

enrolled as of such date, and, three, include a process for the enrollment of individuals made eligible for health care services under subsection b or c of section 10026789b, availability of applications. each state health security program shall make applications for enrollment under the program of eligibility. one, at the employment and payroll ostleses of imloifers locate in the state. at local ooftses of the social security administration. three, at social services locations. four, at outreach sites such as provider and practitioner locations and five at other locations including post offices and schools access to believe a broad cross-section of individuals eligible to enroll. c, issuance of health securitied cards. in conjunction a an individual's eligibility for enrollments, the state health security program shall provide for the issuance of a health security card that shall be used for purposes of identification and processing of claims for benefits under the program.

the state health security program may provide for issuance of such cards by employers for purposes of carrying out enrollment pursuant to section a-2. section 1004, portability of benefits. a, in general, to ensure continuous access to benefits for health care services covered under this title, each state health security program, one, shall not impose any minimum period of residence in the state or waiting period in excess of three months before residents of the state are entitled to or eligible for such benefits under the program. two, shall provide continuation of payments for covered health care services to individuals who have terminated their residence in the state and established their residence in another state. for the duration of any waiting period imposed in the state of new residency for establishment, entitlement, or eligibility for such services and, three, shall provide for the payment for health care services covered under this title, provided to

individuals while temporarily absent from the state based on the following principles. a, payment for such health care services is at the rate that is approved by the state health security program in the state in which the services are provided, unless the states agree to a portion of the costs between them in a different manner. b, payment for such health care services provided outside the united states is made on the basis of the amount that would have been paid by the state health security program for similar services rendered in the state, with due regard in the case of hospital services to the size of the hospital, standard of service, and other relevant factors. b, cross-border arranges. a state health security program for a state may negotiator with such a program in an adjacent state a reciprocal arrangement for the coverage under such other program of health care services to enrollees residing in the border region. section 1005, effective date of benefits. benefits shall first be

available under this title for items and services furnished on or after january 1, 2011. section 1006, relationship to existing federal health programs. a, medicare, midicaid, and state children's health insurance program, schip. one, in general, notwithstanding any provision of law, subject to paragraph 2-a, no benefits shall be available under title 18 of the social security act or any item or service furnished after december 31, 2010. b, no individual is entitled to medical assistance under a state plan approved under silt 19 of such act or any item or service furnished after such date. c, no individual is entitled to medical assistance under schip plan under title 21 of such act or any item or service furnished

after such date. and, d, no payment shall be made to a state under section 1903-a or 2105-a of such act with respect to medical assistance or child health assistance for any item or service furnished after such date. 2, transsix. in the case of in-patient hospital services and extended care services during a continuous period of stay which began before january 1, 2011, and which has not ended as of such date, for which benefits are provided under title 18 under estate plan under title 19 or a state child health plan under title 21 of the social security act, the secretary of health and human services and each state plan respectively shall provide for a continuation of benefits under such title or plan until the end of the period of stay. b, federal employees health benefits program. no benefits shall be made available under chapter 81 of

filet 5 united states code for any part of a coverage period occurring after december 31, 2010. c, champ 13us. no benefits shall be made available under section 1079 and 1076 united states code for items or services furnished after december 31, 2010. d, treatment of benefits for veterans and native americans. nothing in this title shall affect the eligibility of veterans for the medical benefits and services provided upper title 38, united states code, or of indians for the medical benefits and services provided by or through the indian health service. subtitle b, comprehensive benefits, including preventative benefits and benefits for long-term care. section 1101. comprehensive benefits. a, in general, subject to the

succeeding provisions of this title, individuals enrolled for benefits under this title are entitled to have payment made under a state health security program for the following items and services if medically necessary or appropriate for maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition. one, hospital services. inpatient and outpatient hospital care, including 24 hour a day emergency services. two, professional services. professional services of health care practitioners authorized to provide health care services under state law, including patient education and training in self-management techniques. three, community-based primary health services. community-based primary health

services, as defined in section 1102-a. four, preventative services. preventative services as defined in section 1102-b. five, long-term, acute, and chronic care services. a, nursing facility services. b, home health services. c, home and community-based long-term care services, as defined in section 1102-c for individuals described in section 1103-a. d, hospice care. e, services in intermediate care facilities for individuals with mental retardation. six, prescription drugs, biologicals, insulin, medical foods. a, outpatient prescription drugs and biologics, as specified by the board consistent with section 1515. b, insulin. c, medical foods as defined in section 1102-e. seven, dental services. dental services as defined in section 1102-h.

eight, mental health and substance abuse treatment services. mental health and substance abuse treatment services, as defined in section 1102-f. 9, diagnostic tests. diagnostic tests. ten, other items and services. a, outpatient therapy. outpatient physical therapy services, outpatient speech pathology services and outpatient occupational therapy services in all settings. b, durable medical equipment. durable medical equipment. c, home dialysis. home dialysis supplies and equipment. d, ambulance. emergency ambulance service. e, prosthetic devices. prosthetic devices, including replacements of such devices. (f) additional items and services.-such other medical or health care items or services as the board may specify. (b) prohibition of balance billing.-no person may impose a charge for covered services for which benefits are provided under this title.

(c) no duplicate health insurance.-each state health security program shall prohibit the sale of health insurance in the state if payment under the insurance duplicates payment for any items or services for which payment may be made under such a program. (d) state program may provide additional benefits.-nothing in this title shall be construed as limiting the benefits that may be made available under a state health security program to residents of the state at the expense of the state. (e) employers may provide additional benefits.-nothing in this title shall be construed as limiting the additional benefits that an employer may provide to employees or their dependents, or to former employees or their dependents.

(e) employers may provide additional benefits.-nothing in this title shall be construed as limiting the additional benefits that an employer may provide to employees or their dependents, or to former employees or their dependents. sec. 1102. definitions relating to services. sec. 1102. definitions relating to services. (a) community-based primary health services.-in this title, the term "community-based primary health services" means ambulatory health services furnished- (1) by a rural health clinic; (2) by a federally qualified health center (as defined in section 1905(l)(2)(b) of the social security act), and which, for purposes of this title,

include services furnished by state and local health agencies; (3) in a school-based setting; (4) by public educational agencies and other providers of services to children entitled to assistance under the individuals with disabilities education act for services furnished pursuant to a written individualized family services plan or individual education plan under such act; and (5) public and private nonprofit entities receiving federal assistance under the public health service act. (b) preventive services.- (1) in general.-in this title, the term "preventive services" means items and services- (a) which- (i) are specified in paragraph (2); or (ii) the board determines to be effective in the maintenance and promotion of health or minimizing the effect of illness, disease, or medical condition; and (b) which are provided consistent with the periodicity schedule established under paragraph (3). (2) specified preventive services.-the services specified

in this paragraph are as follows: (a) basic immunizations. (b) prenatal and well-baby care (for infants under 1 year of age). (c) well-child care (including periodic physical examinations, hearing and vision screening, and developmental screening and examinations) for individuals under 18 years of age. (d) periodic screening mammography, pap smears, and and examinations for prostate cancer. (e) physical examinations. (f) family planning services. (g) routine eye examinations, eyeglasses, and contact lenses. (h) hearing aids, but only upon a determination of a certified audiologist or physician that a hearing problem exists and is caused by a condition that can be corrected by use of a hearing aid. (3) schedule.-the board shall establish, in consultation with experts in preventive medicine and public health and taking into consideration those preventive services recommended

by the preventive services task force and published as the guide to clinical preventive services, a periodicity schedule for the coverage of preventive services under paragraph (1). such schedule shall take into consideration the cost-effectiveness of appropriate preventive care and shall be revised not less frequently than once every 5 years, in consultation with experts in preventive medicine and public health. (c) home and community-based long-term care services.-in this title, the term "home and community-based long-term care services" means the following services provided to an individual to enable the individual to remain in such individual's place of residence within the community: (1) home health aide services. (2) adult day health care, social day care or psychiatric day care. (3) medical social work services. (4) care coordination services, as defined in subsection (g)(1). (5) respite care, including training for informal

caregivers. (6) personal assistance services, and homemaker services (including meals) incidental to the provision of personal assistance services. (d) home health services.- (1) in general.-the term "home health services" means items and services described in section 1861(m) of the social security act and includes home infusion services. (2) home infusion services.-the term "home infusion services" includes the nursing, pharmacy, and related services that are necessary to conduct the home infusion of a drug regimen safely and effectively under a plan established and periodically reviewed by a physician and that are provided in compliance with quality assurance requirements established by the secretary. (e) medical foods.-in this title, the term "medical foods" means foods which are formulated to be consumed or administered enterally under the supervision of a physician and which are intended for the specific dietary management of a disease or condition for which

distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. (f) mental health and substance abuse treatment services.- (1) services described.-in this title, the term "mental health and substance abuse treatment services" means the following services related to the prevention, diagnosis, treatment, and rehabilitation of mental illness and promotion of mental health: (a) inpatient hospital services.-inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse for up to 60 days during a year, reduced by a number of days determined by the secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of inpatient residential services furnished to the individual under subparagraph (b) during the year after such services have been furnished to the individual for 120 days during

the year (rounded to the nearest day), but only if (with respect to services furnished to an individual described in section 1104(b)(1)) such services are furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 1104(b)(2). (b) intensive residential services.-intensive residential services (as defined in paragraph (2)) furnished to an individual for up to 120 days during any calendar year, except that- (i) such services may be furnished to the individual for additional days during the year if necessary for the individual to complete a course of treatment to the extent that the number of days of inpatient hospital services described in subparagraph (a) that may be furnished to the individual during the year (as reduced under such subparagraph) is not less than 15; and (ii) reduced by a number of days

determined by the secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of intensive community-based services furnished to the individual under subparagraph (d) during the year after such services have been furnished to the individual for 90 days (or, in the case of services described in subparagraph (d)(ii), for 180 days) during the year (rounded to the nearest day). (c) outpatient services.-outpatient treatment services of mental illness or substance abuse (other than intensive community-based services under subparagraph (d)) for an unlimited number of days during any calendar year furnished in accordance with standards established by the secretary for the management of such services, and, in the case of services furnished to an individual described in section 1104(b)(1) who is not an inpatient of a hospital, in conformity with the plan of an organized system of care for mental health and substance

abuse services in accordance with section 1104(b)(2). (d) intensive community-based services.-intensive community-based services (as described in paragraph (3))- (i) for an unlimited number of days during any calendar year, in the case of services described in section 1861(ff)(2)(e) that are furnished to an individual who is a seriously mentally ill adult, a seriously emotionally disturbed child, or an adult or child with serious substance abuse disorder (as determined in accordance with criteria established by the secretary); (ii) in the case of services described in section 1861(ff)(2)(c), for up to 180 days during any calendar year, except that such services may be furnished to the individual for a number of additional days during the year equal to the difference between the total number of days of intensive residential services which the individual may receive during

the year under part a (as determined under subparagraph (b)) and the number of days of such services which the individual has received during the year; or (iii) in the case of any other such services, for up to 90 days during any calendar year, except that such services may be furnished to the individual for the number of additional days during the year described in clause (ii). (2) intensive residential services defined.- (a) in general.-subject to subparagraphs (b) and (c), the term "intensive residential services" means inpatient services provided in any of the following facilities: (i) residential detoxification centers. (ii) crisis residential programs or mental illness residential treatment programs. (iii) therapeutic family or group treatment homes. (iv) residential centers for substance abuse treatment. (b) requirements for facilities.-no service may be treated as an intensive residential service under subparagraph (a) unless the facility at which the service is provided-

(i) is legally authorized to provide such service under the law of the state (or under a state regulatory mechanism provided by state law) in which the facility is located or is certified to provide such service by an appropriate accreditation entity approved by the state in consultation with the secretary; and (ii) meets such other requirements as the secretary may impose to assure the quality of the intensive residential services provided. (c) services furnished to at-risk children.-in the case of services furnished to an individual described in section 1104(b)(1), no service may be treated as an intensive residential service under this subsection unless the service is furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 1104(b)(2). (d) management standards.-no

service may be treated as an intensive residential service under subparagraph (a) unless the service is furnished in accordance with standards established by the secretary for the management of such services. (3) intensive community-based services defined.- (a) in general.-the term "intensive community-based services" means the items and services described in subparagraph (b) prescribed by a physician (or, in the case of services furnished to an individual described in section 1104(b)(1), by an organized system of care for mental health and substance abuse services in accordance with such section) and provided under a program described in subparagraph (d) under the supervision of a physician (or, to the extent permitted under the law of the state in which the services are furnished, a non-physician mental health professional) pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in

consultation with appropriate staff participating in such program) which sets forth the physician's diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan, but does not include any item or service that is not furnished in accordance with standards established by the secretary for the management of such services. (b) items and services described.-the items and services described in this subparagraph are- (i) partial hospitalization services consisting of the items and services described in subparagraph (c); (ii) psychiatric rehabilitation services; (iii) day treatment services for individuals under 19 years of age; (iv) in-home services; (v) case management services, including collateral services designated as such case management services by the secretary; (vi) ambulatory detoxification services; and (vii) such other items and services as the secretary may

provide (but in no event to include meals and transportation) that are reasonable and necessary for the diagnosis or active treatment of the individual's condition, reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement). (c) items and services included as partial hospitalization services.-for purposes of subparagraph (b)(i), partial hospitalization services consist of the following: (i) individual and group therapy with physicians or psychologists (or other mental health professionals to the extent

authorized under state law). (ii) occupational therapy requiring the skills of a qualified occupational therapist. (iii) services of social workers, trained psychiatric nurses, behavioral aides, and other staff trained to work with psychiatric patients (to the extent authorized under state law). (iv) drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered). (v) individualized activity therapies that are not primarily recreational or diversionary. (vi) family counseling (the primary purpose of which is treatment of the individual's condition). (vii) patient training and education (to the extent that training and educational activities are closely and clearly related to the individual's care and treatment). (viii) diagnostic services. (d) programs described.-a program described in this subparagraph is a program

(whether facility-based or freestanding) which is furnished by an entity- (i) legally authorized to furnish such a program under state law (or the state regulatory mechanism provided by state law) or certified to furnish such a program by an appropriate accreditation entity approved by the state in consultation with the secretary; and (ii) meeting such other requirements as the secretary may impose to assure the quality of the intensive community-based services provided. (g) care coordination services.- (1) in general.-in this title, the term "care coordination services" means services provided by care coordinators (as defined in paragraph (2)) to individuals described in paragraph (3) for the coordination and monitoring of home and community-based long term care services to ensure appropriate, cost-effective utilization of such services in a comprehensive and continuous manner, and includes- (a) transition management between inpatient facilities and

community-based services, including assisting patients in identifying and gaining access to appropriate ancillary services; and (b) evaluating and recommending appropriate treatment services, in cooperation with patients and other providers and in conjunction with any quality review program or plan of care under section 1105. (2) care coordinator.- (a) in general.-in this title, the term "care coordinator" means an individual or nonprofit or public agency or organization which the state health security program determines- (i) is capable of performing directly, efficiently, and effectively the duties of a care coordinator described in paragraph (1); and (ii) demonstrates capability in establishing and periodically reviewing and revising plans of care, and in arranging for and monitoring the provision and quality of services under any plan. (b) independence.-state health

security programs shall establish safeguards to assure that care coordinators have no financial interest in treatment decisions or placements. care coordination may not be provided through any structure or mechanism through which quality review is performed. (3) eligible individuals.-an individual described in this paragraph is an individual described in section 1103 (relating to individuals qualifying for long term and chronic care services). (h) dental services.- (1) in general.-in this title, subject to subsection (b), the term "dental services" means the following: (a) emergency dental treatment, including extractions, for bleeding, pain, acute infections, and injuries to the maxillofacial region. (b) prevention and diagnosis of dental disease, including examinations of the hard and soft tissues of the oral cavity and related structures, radiographs, dental sealants, fluorides, and dental prophylaxis. (c) treatment of dental disease,

including non-cast fillings, periodontal maintenance services, and endodontic services. (d) space maintenance procedures to prevent orthodontic complications. (e) orthodontic treatment to prevent severe malocclusions. (f) full dentures. (g) medically necessary oral health care. (h) any items and services for special needs patients that are not described in subparagraphs (a) through (g) and that- (i) are required to provide such patients the items and services described in subparagraphs (a) through (g); (ii) are required to establish oral function (including general (iii) consist of orthodontic care for severe dentofacial abnormalities; or (iv) consist of prosthetic dental devices for genetic or birth defects or fitting for such devices. (i) any dental care for individuals with a seizure

disorder that is not described in subparagraphs (a) through (h) and that is required because of an illness, injury, disorder, or other health condition that results from such seizure disorder. (2) limitations.-dental services are subject to the following limitations: (a) prevention and diagnosis.- (i) examinations and prophylaxis.-the examinations and prophylaxis described in paragraph (1)(b) are covered only consistent with a periodicity schedule established by the board, which schedule may provide for special treatment of individuals less than 18 years of age and of special needs patients. (ii) dental sealants.-the dental sealants described in such paragraph are not covered for individuals 18 years of age or older. such sealants are covered for individuals less than 10 years of age for protection of the 1st permanent molars. such sealants are covered for individuals 10 years of age or older for protection of the 2d permanent molars. (b) treatment of dental disease.-prior to january 1,

2016, the items and services described in paragraph (1)(c) are covered only for individuals less than 18 years of age and special needs patients. on or after such date, such items and services are covered for all individuals enrolled for benefits under this title, except that endodontic services are not covered for individuals 18 years of age or older. (c) space maintenance.-the items and services described in paragraph (1)(d) are covered only for individuals at least 3 years of age, but less than 13 years of age and- (i) are limited to posterior teeth; (ii) involve maintenance of a space or spaces for permanent posterior teeth that would otherwise be prevented from normal eruption if the space were not maintained; and (iii) do not include a space maintainer that is placed within 6 months of the expected eruption of the permanent posterior tooth concerned. (3) definitions.-for purposes of this title: (a) medically necessary oral

health care.-the term "medically necessary oral health care" means oral health care that is required as a direct result of, or would have a direct impact on, an underlying medical condition. such term includes oral health care directed toward control or elimination of pain, infection, or reestablishment of oral function. (b) special needs patient.-the term "special needs patient" includes an individual with a genetic or birth defect, a developmental disability, or an acquired medical disability. (i) nursing facility; nursing facility services.-except as may be provided by the board, the terms "nursing facility" and "nursing facility services" have the meanings given such terms in sections 1919(a) and 1905(f), respectively, of the social security act. (j) services in intermediate care facilities for individuals with mental retardation.-except as may be provided by the board-

(1) the term "intermediate care facility for individuals with mental retardation" has the meaning specified in section 1905(d) of the social security act (as in effect before the enactment of this title); and (2) the term "services in intermediate care facilities for individuals with mental retardation" means services described in section 1905(a)(15) of such act (as so in effect) in an intermediate care facility for individuals with mental retardation to an individual determined to require such services in accordance with standards specified by the board and comparable to the standards described in section 1902(a)(31)(a) of such act (as so in effect). (k) other terms.-except as may be provided by the board, the definitions contained in section 1861 of the social security act shall apply.

sec. 1103. special rules for home and community-based long-term care services. (a) qualifying individuals.-for purposes of section 1101(a)(5)(c), individuals described in this subsection are the following individuals: (1) adults.-individuals 18 years of age or older determined (in a manner specified by the board)- (a) to be unable to perform, without the assistance of an individual, at least 2 of the following 5 activities of daily living (or who has a similar level of disability due to cognitive impairment)- (i) bathing; (ii) eating; (iii) dressing; (iv) toileting; and (v) transferring in and out of a bed or in and out of a chair; (b) due to cognitive or mental impairments, to require supervision because the individual behaves in a manner that poses health or safety

hazards to himself or herself or others; or (c) due to cognitive or mental impairments, to require queuing to perform activities of daily living. (2) children.-individuals under 18 years of age determined (in a manner specified by the board) to meet such alternative standard of disability for children as the board develops. such alternative standard shall be comparable to the standard for adults and appropriate for children. (b) limit on services.- (1) in general.-the aggregate expenditures by a state health security program with respect to home and community-based long-term care services in a period (specified by the board) may not exceed 65 percent (or such alternative ratio as the board establishes under paragraph (2)) of the average of the amount of payment that would have been made under the program during the period if all the home-based long-term care

beneficiaries had been residents of nursing facilities in the same area in which the services were provided. (2) alternative ratio.-the board may establish for purposes of paragraph (1) an alternative ratio (of payments for home and community-based long term care services to payments for nursing facility services) as the board determines to be more consistent with the goal of providing cost-effective long-term care in the most appropriate and least restrictive setting. sec. 1104. exclusions and limitations. (a) in general.-subject to section 1101(e), benefits for service are not available under this title unless the services meet the standards specified in section 1101(a). (b) special delivery requirements for mental health and substance abuse treatment services provided to at-risk children. (1) requiring services to be provided through organized systems of care.-a state health security program shall ensure that mental health services and

substance abuse treatment services are furnished through an organized system of care, as described in paragraph (2), if- (a) the services are provided to an individual less than 22 years of age; (b) the individual has a serious emotional disturbance or a substance abuse disorder; and (c) the individual is, or is at imminent risk of being, subject to the authority of, or in need of the services of, at least 1 public agency that serves the needs of children, including an agency involved with child welfare, special education, juvenile justice, or criminal justice. (2) requirements for system of care.-in this subsection, an "organized system of care" is a community-based service delivery network, which may consist of public and private providers, that meets the following requirements: (a) the system has established linkages with existing mental health services and substance abuse treatment service delivery programs in the plan service area (or is in the process of developing or operating a system with appropriate public agencies in the area to coordinate the delivery of such services to individuals in the area).

(b) the system provides for the participation and coordination of multiple agencies and providers that serve the needs of children in the area, including agencies and providers involved with child welfare, education, juvenile justice, criminal justice, health care, mental health, and substance abuse prevention and treatment. (c) the system provides for the involvement of the families of children to whom mental health services and substance abuse treatment services are provided in the planning of treatment and the delivery of services. (d) the system provides for the development and implementation of individualized treatment plans by multidisciplinary and multiagency teams, which are recognized and followed by the applicable agencies and providers in the area. (e) the system ensures the delivery and coordination of the range of mental health services and substance abuse treatment services required by individuals under 22 years of age who have a serious emotional disturbance or a substance abuse disorder. (f) the system provides for the management of the individualized treatment plans described in subparagraph (d) and for a

flexible response to changes in treatment needs over time. (c) treatment of experimental services. in applying subsection (a), the board shall make national coverage determinations with respect to those services that are experimental in nature. such determinations shall be made consistent with a process that provides for input from representatives of health care professionals and patients and public comment. (d) application of practice guidelines. in the case of services for which the american health security quality council (established under section 1401) has recognized a national practice guideline, the services are considered to meet the standards specified in section 1101(a) if they have been provided in accordance with such guideline or in accordance with such guidelines as are provided by the state health security program consistent with subtitle e. for purposes of this subsection, a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline.

(e) specific limitations. (1) limitations on eyeglasses, contact lenses, hearing aids, and durable medical and durable medical equipment. subject to section 1101(e), the board may impose such limits relating to the costs and frequency of replacement of eyeglasses, contact lenses, hearing aids, and durable medical equipment to which individuals enrolled for benefits under this title are entitled to have payment made under a state health security program as the board deems appropriate. (2) overlap with preventive services. the coverage of services described in section 1101(a) (other than paragraph (3)) which also are preventive services are required to be covered only to the extent that they are required to be covered as preventive services. (3) miscellaneous exclusions from covered services. covered services under this title do not include the following: (a) surgery and other procedures (such as orthodontia) performed solely for cosmetic purposes (as defined in regulations) and hospital or other services incident thereto, unless- (i) required to correct a congenital anomaly;

(ii) required to restore or correct a part of the body which has been altered as a result of accidental injury, disease, or surgery; or (iii) otherwise determined to be medically necessary and appropriate under section 1101(a). (b) personal comfort items or private rooms in inpatient facilities, unless determined to be medically necessary and appropriate under section 1101(a). (c) the services of a professional practitioner if they are furnished in a hospital or other facility which is not a participating provider. (f) nursing facility services and home health and home health services. nursing facility services and home health services (other than post-hospital services, as defined by the board) furnished to an individual who is not described in section 1103(a) are not covered services unless the services are determined to meet the standards specified in section 1101(a) and, with respect to nursing facility services, to be provided in the least restrictive and most appropriate setting. sec. 1105. certification; quality review; plans of care.

(a) certifications. state health security programs may require, as a condition of payment for institutional health care services and other services of the type described in such sections 1814(a) and 1835(a) of the social security act, periodic professional certifications of the kind described in such sections. (b) quality review. for requirement that each state health security program establish a quality review program that meets the requirements for such a program under subtitle e, see section 1304(b)(1)(h). (c) plan of care requirements. a state health security program may require, consistent with standards established by the board, that payment for services exceeding specified levels or duration be provided only as consistent with a plan of care or treatment formulated by one or more providers of the services or other qualified professionals. such a plan may include, consistent with subsection (b), case management at specified intervals as a further condition of payment for services. subtitle c-provider participation

sec. 1201. provider participation and standards. (a) in general. an individual or other entity furnishing any covered service under a state health security program under this title is not a qualified provider unless the individual or entity- (1) is a qualified provider of the services under section 1202; (2) has filed with the state health security program a participation agreement described in subsection (b); and (3) meets such other qualifications and conditions as are established by the board or the state health security program under this title. (b) requirements in participation agreement.- (1) in general. a participation agreement described in this subsection between a state health security program and a provider shall provide at least for the following: (a) services to eligible persons will be furnished by the provider without discrimination on the ground of race, national origin, income, religion, age, sex or sexual orientation, disability, handicapping condition, or (subject to the professional qualifications of

s the provider) illness. nothing in this subparagraph shall be construed as requiring the provision of a type or class of services which services are outside the scope of the provider's normal practice. (b) no charge will be made for any covered services other than for payment authorized by this title. (c) the provider agrees to furnish such information as may be reasonably required by the board or a state health security program, in accordance with uniform reporting standards established under section 1301(g)(1), for- (i) quality review by designated entities; (ii) the making of payments under this title (including the examination of records as may be necessary for the verification of information on which payments are based); (iii) statistical or other studies required for the implementation of this title; and (iv) such other purposes as the board or state may specify. (d) the provider agrees not to bill the program for any services for which benefits are not available because of section 1104(d). (e) in the case of a provider that is not an individual, the provider agrees not to employ or use for the provision of health

services any individual or other provider who or which has had a participation agreement under this subsection terminated for cause. (f) in the case of a provider paid under a fee-for-service basis under section 1511, the provider agrees to submit bills and any required supporting documentation relating to the provision of covered services within 30 days (or such shorter period as a state health security program may require) after the date of providing such services. (2) termination of participation agreements.- (a) in general. participation agreements may be terminated, with appropriate notice- (i) by the board or a state health security program for failure to meet the requirements of this title; or (ii) by a provider. (b) termination process. providers shall be provided notice and a reasonable opportunity to correct deficiencies before the board or a state health security program terminates an agreement unless a more immediate termination is required for public safety or similar reasons. sec. 1202. qualifications for providers. o

(a) in general. a health care provider is considered to be qualified to provide covered services if the provider is licensed or certified and meets- (1) all the requirements of state law to provide such services; (2) applicable requirements of federal law to provide such services; and (3) any applicable standards established under subsection (b). (b) minimum provider standards.- (1) in general. the board shall establish, evaluate, and update national minimum standards to assure the quality of services provided under this title and to monitor efforts by state health security programs to assure the quality of such services. a state heth security program may also establish additional minimum standards which providers must meet. (2) national minimum standards.-the national minimum standards under paragraph (1) shall be established for institutional providers of services, individual health care practitioners, and comprehensive health service organizations. except as the board may specify in order to carry out this title, a hospital, nursing facility, or other institutional provider of services shall meet standards for such a facility under the medicare program under title xviii of the social

security act. such standards also may include, where appropriate, elements relating to- (a) adequacy and quality of facilities; (b) training and competence of personnel (including continuing education requirements); (c) comprehensiveness of service; (d) continuity of service; (e) patient satisfaction (including waiting time and access to services); and (f) performance standards (including organization, facilities, structure of services, efficiency of operation, and outcome in palliation, improvement of health, stabilization, cure, or rehabilitation). (3) transition in (3) transition in application. if the board provides for additional requirements for providers under this subsection, any such additional requirement shall be implemented in a manner that provides for a reasonable period during which a previously qualified provider is permitted to meet such an additional requirement. (4) exchange of information.-the board shall provide for an exchange, at least annually, among state health security

programs of information with respect to quality assurance and cost containment. sec. 1203. qualifications for comprehensive health service organizations. (a) in general. for purposes of this title, a comprehensive health service organization (in this section referred to as a "chso") is a public or private organization which, in return for a capitated payment amount, undertakes to furnish, arrange for the provision of, or provide payment with respect to- (1) a full range of health services (as identified by the board), including at least hospital services and physicians services; and (2) out-of-area coverage in the case of urgently needed services; to an identified population which is living in or near a specified service area and which enrolls voluntarily in the organization. (b) enrollment.- (1) in general. all eligible persons living in or near the specified service area of a chso are eligible to enroll in the organization; except that the number of enrollees may be limited to avoid overtaxing the resources of the organization.

(2) minimum enrollment period. subject to paragraph (3), the minimum period of enrollment with a chso shall be twelve months, unless the enrolled individual becomes ineligible to enroll with the organization. (3) withdrawal for cause. each chso shall permit an enrolled individual to disenroll from the organization for cause at any time. (c) requirements for chsos. (1) accessible services. each chso, to the maximum extent feasible, shall make all services readily and promptly accessible to enrollees who live in the specified service area. (2) continuity of care. each chso shall furnish services in such manner as to provide continuity of care and (when services are furnished by different providers) shall provide ready referral of patients to such services and at such times as may be medically appropriate. (3) board of directors. in the case of a chso that is a private organization-

(a) consumer representation. at least one-third of the members of the chso's board of directors must be consumer members with no direct or indirect, personal or family financial relationship to the organization. (b) provider representation. the chso's board of directors must include at least one member who represents health care providers. (4) patient grievance program. each chso must have in effect a patient grievance program and must conduct regularly surveys of the satisfaction of members with services provided by or through the organization. (5) medical standards. each chso must provide that a committee or committees of health care practitioners associated with the organization will promulgate medical standards, oversee the professional aspects of the delivery of care, perform the functions of a pharmacy and drug therapeutics committee, and monitor and review the quality of all health services (including drugs, education, and preventive services). (6) premiums. premiums or other charges by a chso for any services not paid for under this title must be reasonable.

(7) utilization and bonus information. each chso must- (a) comply with the requirements of section 1876(i)(8) of the social security act (relating to prohibiting physician incentive plans that provide specific inducements to reduce or limit medically necessary services); and (b) make available to its membership utilization information and data regarding financial performance, including bonus or incentive payment arrangements to practitioners. (8) provision of services to enrollees at institutions operating under global budgets.-the organization shall arrange to reimburse for hospital services and other facility-based services (as identified by the board) for services provided to members of the organization in accordance with the global operating budget of the hospital or facility approved under section 1510. (9) broad marketing.-each chso must provide for the marketing of its services (including dissemination of marketing materials) to potential enrollees in a manner that is designed to enroll individuals representative of the different

population groups and geographic areas included within its service area and meets such requirements as the board or a state health security program may specify. (10) additional requirements.-each chso must meet- (a) such requirements relating to minimum enrollment; (b) such requirements relating to financial solvency; (c) such requirements relating to quality and availability of care; and (d) such other requirements as the board or a state health security program may specify. (d) provision of emergency services to nonenrollees.-a chso may furnish emergency services to persons who are not enrolled in the organization. payment for such services, if they are covered services to eligible persons, shall be made to the organization unless the organization requests that it be made to the individual provider who furnished the services. sec. 1204. limitation on certain physician referrals. (a) application to american health security program.-section 1877 of the social security act, as amended by subsections (b)

and (c), shall apply under this title in the same manner as it applies under title xviii of the social security act; except that in applying such section under this title any references in such section to the secretary or title xviii of the social security act are deemed references to the board and the american health security program under this title, respectively. (b) expansion of prohibition to certain additional designated services.-section 1877(h)(6) of the social security act (42 u.s.c. 1395nn(h)(6)) is amended by adding at the end the following: "(m) ambulance services. "(n) home infusion therapy services.". (c) conforming amendments.-section 1877 of such act is further amended- (1) in subsection (a)(1)(a), by striking "for which payment otherwise may be made under this title" and inserting "for which a charge is imposed"; (2) in subsection (a)(1)(b), by striking "under this title"; (3) by amending paragraph (1) of subsection (g) to read as follows:

"(1) denial of payment.-no payment may be made under a state health security program for a designated health service for which a claim is presented in violation of subsection no individual, third party payor, or other entity is liable for payment for designated health services for which a claim is presented in violation of such subsection."; and (4) in subsection (g)(3), by striking "for which payment may not be made under paragraph (1)" and inserting "for which such a claim may not be presented under subsection (a)(1)". subtitle d-administration part i-general administrative provisions sec. 1301. american health security standards board. (a) establishment.-there is hereby established an american health security standards board. (b) appointment and terms of members.- (1) in general.-the board shall be composed of- (a) the secretary of health and human services; and (b) 6 other individuals (described in paragraph (2)) appointed by the president with the advice and consent of the senate. the president shall first

nominate individuals under subparagraph (b) on a timely basis so as to provide for the operation of the board by not later than january 1, 2010. (2) selection of appointed members.-with respect to the individuals appointed under paragraph (1)(b): (a) they shall be chosen on the basis of backgrounds in health policy, health economics, the healing professions, and the administration of health care institutions. (b) they shall provide a balanced point of view with respect to the various health care interests and at least 2 of them shall represent the interests of individual consumers. (c) not more than 3 of them shall be from the same political party. (d) to the greatest extent feasible, they shall represent the various geographic regions of the united states and shall reflect the racial, ethnic, and gender composition of the population of the united states. (3) terms of appointed members.-individuals appointed under paragraph (1)(b) shall serve for a term of 6 years, except that the terms of 5 of the individuals initially appointed shall be, as designated by the president at the time of their appointment, for 1, 2, 3, 4, and 5 years.

during a term of membership on the board, no member shall engage in any other business, vocation or employment. (c) vacancies.- (1) in general.-the president shall fill any vacancy in the membership of the board in the same manner as the original appointment. the vacancy shall not affect the power of the remaining members to execute the duties of the board. (2) vacancy appointments.-any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed. (3) reappointment.-the president may reappoint an appointed member of the board for a second term in the same manner as the original appointment. a member who has served for 2 consecutive 6-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve. (4) removal for cause.-upon confirmation, members of the board may not be removed except by the president for cause. (d) chair.-the president shall designate 1 of the members of the board, other than the secretary, to serve at the will of the president as chair of the board. (e) compensation.-members of the board (other than the secretary) shall be entitled to compensation at a level

equivalent to level ii of the executive schedule, in accordance with section 5313 of title 5, united states code. (f) general duties of the board.- (1) in general.-the board shall develop policies, procedures, guidelines, and requirements to carry out this title, including those related to- (a) eligibility; (b) enrollment; (c) benefits; (d) provider participation standards and qualifications, as defined in subtitle c; (e) national and state funding levels; (f) methods for determining amounts of payments to providers of covered services, consistent with part ii of subtitle d; (g) the determination of medical necessity and appropriateness with respect to coverage of certain services; (h) assisting state health security programs with planning for capital expenditures and service delivery; (i) planning for health professional education funding (as specified in subtitle e); and (j) encouraging states to develop regional planning mechanisms (described in section 1304(a)(3)). (2) regulations.-regulations

authorized by this title shall be issued by the board in accordance with the provisions of section 553 of title 5, united states code. (g) uniform reporting standards; annual report; studies.- (1) uniform reporting standards.- (a) in general.-the board shall establish uniform reporting requirements and standards to ensure an adequate national data base regarding health services practitioners, services and finances of state health security programs, approved plans, providers, and the costs of facilities and practitioners providing services. such standards shall include, to the maximum extent feasible, health outcome measures. (b) reports.-the board shall analyze regularly information reported to it, and to state health security programs pursuant to such requirements and standards. (2) annual report.-beginning january 1, of the second year beginning after the date of the enactment of this title, the board shall annually report to congress on the following: (a) the status of implementation of the act. (b) enrollment under this title. (c) benefits under this title. (d) expenditures and financing

under this title. (e) cost-containment measures and achievements under this title. (f) quality assurance. (g) health care utilization patterns, including any changes attributable to the program. (h) long-range plans and goals for the delivery of health services. (i) differences in the health status of the populations of the different states, including income and racial characteristics. (j) necessary changes in the education of health personnel. (k) plans for improving service to medically underserved populations. (l) transition problems as a result of implementation of this title. (m) opportunities for improvements under this title. (3) statistical analyses and other studies.-the board may, either directly or by contract- (a) make statistical and other studies, on a nationwide, regional, state, or local basis, of any aspect of the operation of this title, including studies of the effect of the act upon the health of the people of the united states and the effect of comprehensive health services upon the health of persons receiving such services; (b) develop and test methods of providing through payment for

services or otherwise, additional incentives for adherence by providers to standards of adequacy, access, and quality; methods of consumer and peer review and peer control of the utilization of drugs, of laboratory services, and of other services; and methods of consumer and peer review of the quality of services; (c) develop and test, for use by the board, records and information retrieval systems and budget systems for health services administration, and develop and test model systems for use by providers of services; (d) develop and test, for use by providers of services, records and information retrieval systems useful in the furnishing of preventive or diagnostic services; (e) develop, in collaboration with the pharmaceutical profession, and test, improved administrative practices or improved methods for the reimbursement of independent pharmacies for the cost of furnishing drugs as a covered service; and (f) make such other studies as it may consider necessary or promising for the evaluation, or for the improvement, of the operation of this title.

(4) report on use of existing federal health care facilities.-not later than 1 year after the date of the enactment of this title, the board shall recommend to the congress one or more proposals for the treatment of health care facilities of the federal government. (h) executive director.- (1) appointment.-there is hereby established the position of executive director of the board. the director shall be appointed by the board and shall serve as secretary to the board and perform such duties in the administration of this subtitle as the board may assign. (2) delegation.-the board is authorized to delegate to the director or to any other officer or employee of the board or, with the approval of the secretary of health and human services (and subject to reimbursement of identifiable costs), to any other officer or employee of the department of health and human services, any of its functions or duties under this title other than- (a) the issuance of regulations; or (b) the determination of the availability of funds and their allocation to implement this title. (3) compensation.-the executive director of the board shall be entitled to compensation at a level equivalent to level iii of

the executive schedule, in accordance with section 5314 of title 5, united states code. (i) inspector general.-the inspector general act of 1978 (5 u.s.c. app.) is amended- (1) in section 12(1), by inserting after "corporation;" the first place it appears the following: "the chair of the american health security standards board;"; (2) in section 12(2), by inserting after "resolution trust corporation," the following: "the american health security standards board,"; and (3) by inserting before section 9 the following: "special provisions concerning american health security standards board "sec. 8m. the inspector general of the american health security standards board, in addition to the other authorities vested by this act, shall have the same authority, with respect to the board and the american health security program under this act, as the inspector general for the department of health and human services has with respect to the secretary of health and human services and the medicare and medicaid programs, respectively.". (j) staff.-the board shall

employ such staff as the board may deem necessary. (k) access to information.-the secretary of health and human services shall make available to the board all information available from sources within the department or from other sources, pertaining to the duties of the board. sec. 1302. american health security advisory council. (a) in general.-the board shall provide for an american health security advisory council (in this section referred to as the "council") to advise the board on its activities. (b) membership.-the council shall be composed of- (1) the chair of the board, who shall serve as chair of the council; and (2) twenty members, not otherwise in the employ of the united states, appointed by the board without regard to the provisions of title 5, united states code, governing appointments in the competitive service. the appointed members shall include, in accordance with subsection (e), individuals who are representative of state health security programs, public health professionals, providers of health services, and of individuals (who shall

constitute a majority of the council) who are representative of consumers of such services, including a balanced representation of employers, unions, consumer organizations, and population groups with special health care needs. to the greatest extent feasible, the membership of the council shall represent the various geographic regions of the united states and shall reflect the racial, ethnic, and gender composition of the population of the united states. (c) terms of members.-each appointed member shall hold office for a term of 4 years, except that- (1) any member appointed to fill a vacancy occurring during the term for which the member's predecessor was appointed shall be appointed for the remainder of that term; and (2) the terms of the members first taking office shall expire, as designated by the board at the time of appointment, 5 at the end of the first year, 5 at the end of the second year, 5 at the end of the third year, and 5 at the end of the fourth year after the date of enactment of this act. (d) vacancies.- (1) in general.-the board shall fill any vacancy in the membership of the council in the same manner as the original appointment. the vacancy shall

not affect the power of the remaining members to execute the duties of the council. (2) vacancy appointments.-any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed. (3) reappointment.-the board may reappoint an appointed member of the council for a second term in the same manner as the original appointment. (e) qualifications.- (1) public health representatives.-members of the council who are representative of state health security programs and public health professionals shall be individuals who have extensive experience in the financing and delivery of care under public health programs. (2) providers.-members of the council who are representative of providers of health care shall be individuals who are outstanding in fields related to medical, hospital, or other health activities, or who are representative of organizations or associations of professional health practitioners. (3) consumers.-members who are representative of consumers of such care shall be individuals, not engaged in and having no financial interest in the furnishing of health services, who are familiar with the needs of various segments of the population for personal health

services and are experienced in dealing with problems associated with the consumption of such services. (f) duties.- (1) in general.-it shall be the duty of the council- (a) to advise the board on matters of general policy in the administration of this title, in the formulation of regulations, and in the performance of the board's duties under section 1301; and &h this title and the utilization of health services under it, with a view to recommending any changes in the administration of the act or in its provisions which may appear desirable. (2) report.-the council shall make an annual report to the board on the performance of its functions, including any recommendations it may have with respect thereto, and the board shall promptly transmit the report to the congress, together with a report by the board on any recommendations of the council that have not been followed. (g) staff.-the council, its members, and any committees of the council shall be provided with such secretarial, clerical,

or other assistance as may be authorized by the board for carrying out their respective functions. (h) meetings.-the council shall meet as frequently as the board deems necessary, but not less than 4 times each year. upon request by 7 or more members it shall be the duty of the chair to call a meeting of the council. (i) compensation.-members of the council shall be reimbursed by the board for travel and per diem in lieu of subsistence expenses during the performance of duties of the board in accordance with subchapter i of chapter 57 of title 5, united states code. (j) faca not applicable.-the provisions of the federal advisory committee act shall not apply to the council. sec. 1303. consultation with private entities. the secretary and the board shall consult with private entities, such as professional societies, national associations, nationally recognized associations of

experts, medical schools and academic health centers, consumer groups, and labor and business organizations in the formulation of guidelines, regulations, policy initiatives, and information gathering to assure the broadest and most informed input in the administration of this title. nothing in this title shall prevent the secretary from adopting guidelines developed by such a private entity if, in the secretary's and board's judgment, such guidelines are generally accepted as reasonable and prudent and consistent with this title. sec. 1304. state health security programs. (a) submission of plans.- (1) in general.-each state shall submit to the board a plan for a state health security program for providing for health care services to the residents of the state in accordance with this title. (2) regional programs.-a state may join with 1 or more neighboring states to submit to the board a plan for a regional health security program instead of separate state health security programs.

(3) regional planning mechanisms.-the board shall provide incentives for states to develop regional planning mechanisms to promote the rational distribution of, adequate access to, and efficient use of, tertiary care facilities, equipment, and services. (b) review and approval of plans.- (1) in general.-the board shall review plans submitted under subsection (a) and determine whether such plans meet the requirements for approval. the board shall not approve such a plan unless it finds that the plan (or state law) provides, consistent with the provisions of this title, for the following: (a) payment for required health services for eligible individuals in the state in accordance with this title. (b) adequate administration, including the designation of a single state agency responsible for the administration (or supervision of the administration) of the program. (c) the establishment of a state health security budget. (d) establishment of payment methodologies (consistent with part ii of subtitle e).

(e) assurances that individuals have the freedom to choose practitioners and other health care providers for services covered under this title. (f) a procedure for carrying out long-term regional management and planning functions with respect to the delivery and distribution of health care services that- (i) ensures participation of consumers of health services and providers of health services; and (ii) gives priority to the most acute shortages and maldistributions of health personnel and facilities and the most serious deficiencies in the delivery of covered services and to the means for the speedy alleviation of these shortcomings. (g) the licensure and regulation of all health providers and facilities to ensure compliance with federal and state laws and to promote quality of care. (h) establishment of an independent ombudsman for consumers to register complaints about the organization and administration of the state health security program and to help resolve complaints and disputes between consumers and providers. (i) publication of an annual

report on the operation of the state health security program, which report shall include information on cost, progress towards achieving full enrollment, public access to health services, quality review, health outcomes, health professional training, and the needs of medically underserved populations. (j) provision of a fraud and abuse prevention and control unit that the inspector general determines meets the requirements of section 1309(a). (k) prohibit payment in cases of prohibited physician referrals under section 1204. (2) consequences of failure to comply.-if the board finds that a state plan submitted under paragraph (1) does not meet the requirements for approval under this section or that a state health security program or specific portion of such program, the plan for which was previously approved, no longer meets such requirements, the board shall provide notice to the state of such failure and that unless corrective action is taken within a period specified by the board, the board shall

place the state health security program (or specific portions of such program) in receivership under the jurisdiction of the board. (c) state health security advisory councils.- (1) in general.-for each state, the governor shall provide for appointment of a state health security advisory council to advise and make recommendations to the governor and state with respect to the implementation of the state health security program in the state. (2) membership.-each state health security advisory council shall be composed of at least 11 individuals. the appointed members shall include individuals who are representative of the state health security program, public health professionals, providers of health services, and of individuals (who shall constitute a majority) who are representative of consumers of such services, including a balanced representation of employers, unions and consumer organizations. to the greatest extent feasible, the membership of each state health security advisory council shall represent the various geographic regions of the state and shall reflect

the racial, ethnic, and gender composition of the population of the state. (3) duties.- (a) in general.-each state health security advisory council shall review, and submit comments to the governor concerning the implementation of the state health security program in the state. (b) assistance.-each state health security advisory council shall provide assistance and technical support to community organizations and public and private non-profit agencies submitting applications for funding under appropriate state and federal public health programs, with particular emphasis placed on assisting those applicants with broad consumer representation. (d) state use of fiscal agents.- (1) in general.-each state health security program, using competitive bidding procedures, may enter into such contracts with qualified entities, such as voluntary associations, as the state determines to be appropriate to process claims and to perform other related functions of fiscal agents under

the state health security program. (2) restriction.-except as the board may provide for good cause shown, in no case may more than 1 contract described in paragraph (1) be entered into under a state health security program. sec. 1305. complementary conduct of related health programs. in performing functions with respect to health personnel education and training, health research, environmental health, disability insurance, vocational rehabilitation, the regulation of food and drugs, and all other matters pertaining to health, the secretary of health and human services shall direct all activities of the department of health and human services toward contributions to the health of the people complementary to this title. part ii-control over fraud and abuse sec. 1310. application of federal sanctions to all fraud and abuse under american health security program. the following sections of the social security act shall apply to state health security programs in the same manner as they apply to state medical assistance plans under title xix

of such act (except that in applying such provisions any reference to the secretary is deemed a reference to the board): (1) section 1128 (relating to exclusion of individuals and entities). (2) section 1128a (civil monetary penalties). (3) section 1128b (criminal penalties). (4) section 1124 (relating to disclosure of ownership and related information). (5) section 1126 (relating to disclosure of certain owners). sec. 1311. requirements for operation of state health care fraud and abuse control units. (a) requirement.-in order to meet the requirement of section 1304(b)(1)(j), each state health security program must establish and maintain a health care fraud and abuse control unit (in this section referred to as a "fraud unit") that meets requirements of this section and other requirements of the board. such a unit may be a state medicaid fraud control unit (described in

section 1903(q) of the social security act). (b) structure of unit.-the fraud unit must- (1) be a single identifiable entity of the state government; (2) be separate and distinct from the state agency with principal responsibility for the administration of the state health security program; and (3) meet 1 of the following requirements: (a) it must be a unit of the office of the state attorney general or of another department of state government which possesses statewide authority to prosecute individuals for criminal violations. (b) if it is in a state the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the board, that- (i) assure its referral of suspected criminal violations relating to the state health insurance plan to the appropriate authority or authorities in the states for prosecution; and (ii) assure its assistance of, and coordination with, such authority or authorities in such

prosecutions. (c) it must have a formal working relationship with the office of the state attorney general and have formal procedures (including procedures for its referral of suspected criminal violations to such office) which are approved by the board and which provide effective coordination of activities between the fraud unit and such office with respect to the detection, investigation, and prosecution of suspected criminal violations relating to the state health insurance plan. (c) functions.-the fraud unit must- (1) have the function of conducting a statewide program for the investigation and prosecution of violations of all applicable state laws regarding any and all aspects of fraud in connection with any aspect of the provision of health care services and activities of providers of such services under the state health security program; (2) have procedures for reviewing complaints of the abuse and neglect of patients of providers and facilities that receive payments under the state health security program, and, where appropriate, for acting

upon such complaints under the criminal laws of the state or for referring them to other state agencies for action; and (3) provide for the collection, or referral for collection to a single state agency, of overpayments that are made under the state health security program to providers and that are discovered by the fraud unit in carrying out its activities. (d) resources.-the fraud unit must- (1) employ such auditors, attorneys, investigators, and other necessary personnel; (2) be organized in such a manner; and (3) provide sufficient resources (as specified by the board) as is necessary to promote the effective and efficient conduct of the unit's activities. (e) cooperative agreements.-the fraud unit must have cooperative agreements (as specified by the board) with- (1) similar fraud units in other states; (2) the inspector general; and (3) the attorney general of the united states. (f) reports.-the fraud unit must submit to the inspector general

an application and annual reports containing such information as the inspector general determines to be necessary to determine whether the unit meets the previous requirements of this section. subtitle e-quality assessment sec. 1401. american health security quality council. (a) establishment.-there is hereby established an american health security quality council (in this subtitle referred to as the "council"). (b) duties of the council.-the council shall perform the following duties: (1) practice guidelines.-the council shall review and evaluate each practice guideline developed under part b of title ix of the public health service act. the council shall determine whether the guideline should be recognized as a national practice guideline to be used under section 1104(d) for purposes of determining payments under a state health security program. (2) standards of quality, performance measures, and medical review criteria.-the council shall review and

evaluate each standard of quality, performance measure, and medical review criterion developed under part b of title ix of the public health service act. the council shall determine whether the standard, measure, or criterion is appropriate for use in assessing or reviewing the quality of services provided by state health security programs, health care institutions, or health care professionals. (3) criteria for entities conducting quality reviews.-the council shall develop minimum criteria for competence for entities that can qualify to conduct ongoing and continuous external quality review for state quality review programs criteria shall require such an entity to be administratively independent of the individual or board that administers the state health security program and shall ensure that such entities do not provide financial incentives to reviewers to favor one pattern of practice over another. the council shall ensure coordination and reporting by such entities to assure national consistency in

quality standards. (4) reporting.-the council shall report to the board annually on the conduct of activities under such title and shall report to the board annually specifically on findings from outcomes research and development of practice guidelines that may affect the board's determination of coverage of services under section 401(f)(1)(g). (5) other functions.-the council shall perform the functions of the council described in section 1402. (c) appointment and terms of members.- (1) in general.-the council shall be composed of 10 members appointed by the president. the president shall first appoint individuals on a timely basis so as to provide for the operation of the council by not later than january 1, 2010. (2) selection of members.-each member of the council shall be a member of a health profession. five members of the council shall be physicians. individuals shall be appointed to the council on the basis of national reputations for clinical and

academic excellence. to the greatest extent feasible, the membership of the council shall represent the various geographic regions of the united states and shall reflect the racial, ethnic, and gender composition of the population of the united states. (3) terms of members.-individuals appointed to the council shall serve for a term of 5 years, except that the terms of 4 of the individuals initially appointed shall be, as designated by the president at the time of their appointment, for 1, 2, 3, and 4 years. (d) vacancies.- (1) in general.-the president shall fill any vacancy in the membership of the council in the same manner as the original appointment. the vacancy shall not affect the power of the remaining members to execute the duties of the council. (2) vacancy appointments.-any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed. (3) reappointment.-the president may reappoint a member of the council for a second term in the

same manner as the original appointment. a member who has served for 2 consecutive 5-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve. (e) chair.-the president shall designate 1 of the members of the council to serve at the will of the president as chair of the council. (f) compensation.-members of the council who are not employees of the federal government shall be entitled to compensation at a level equivalent to level ii of the executive schedule, in accordance with section 5313 of title 5, united states code. sec. 1402. development of certain methodologies, guidelines, and standards. (a) profiling of patterns of practice; identification of outliers.-the council shall adopt methodologies for profiling the patterns of practice of health care professionals and for identifying outliers (as defined in subsection (e)). (b) centers of excellence.-the council shall develop guidelines for certain medical procedures designated by the board to be

performed only at tertiary care centers which can meet standards for frequency of procedure performance and intensity of support mechanisms that are consistent with the high probability of desired patient outcome. reimbursement under this act for such a designated procedure may only be provided if the procedure was performed at a center that meets such standards. (c) remedial actions.-the council shall develop standards for education and sanctions with respect to outliers so as to assure the quality of health care services provided under this act. the council shall develop criteria for referral of providers to the state licensing board if education proves ineffective in correcting provider practice behavior. (d) dissemination.-the council shall disseminate to the state- (1) the methodologies adopted under subsection (a); (2) the guidelines developed under subsection (b); and (3) the standards developed under subsection (c); for use by the states under section 1403.

(e) outlier defined.-in this title, the term "outlier" means a health care provider whose pattern of practice, relative to applicable practice guidelines, suggests deficiencies in the quality of health care services being provided. sec. 1403. state quality review programs. (a) requirement.-in order to meet the requirement of section 404(b)(1)(h), each state health security program shall establish 1 or more qualified entities to conduct quality reviews of persons providing covered services under the program, in accordance with standards established under subsection (b)(1) (except as provided in subsection (b)(2)) and subsection (d). (b) federal standards.- (1) in general.-the council shall establish standards with respect to- (a) the adoption of practice guidelines (whether developed by the federal government or other entities); (b) the identification of outliers (consistent with methodologies adopted under section 1402(a));

(c) the development of remedial programs and monitoring for outliers; and (d) the application of sanctions (consistent with the standards developed under section 1402(c)). (2) state discretion.-a state may apply under subsection (a) standards other than those established under paragraph (1) so long as the state demonstrates to the satisfaction of the council on an annual basis that the standards applied have been as efficacious in promoting and achieving improved quality of care as the application of the standards established under paragraph (1). positive improvements in quality shall be documented by reductions in the variations of clinical care process and improvement in patient outcomes. (c) qualifications.-an entity is not qualified to conduct quality reviews under subsection (a) unless the entity satisfies the criteria for competence for such entities developed by the council under section 1401(b)(3).

(d) internal quality review.-nothing in this section shall preclude an institutional provider from establishing its own internal quality review and enhancement programs. sec. 1404. elimination of utilization review programs; transition. (a) intent.-it is the intention of this title to replace by january 1, 2013, random utilization controls with a systematic review of patterns of practice that compromise the quality of care. (b) superseding case reviews.- (1) in general.-subject to the succeeding provisions of this subsection, the program of quality review provided under the previous sections of this title supersede all existing federal requirements for utilization review programs, including requirements for random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis. (2) transition.-before january

1, 2013, the board and the states may employ existing utilization review standards and mechanisms as may be necessary to effect the transition to pattern of practice-based reviews. (3) construction.-nothing in this subsection shall be construed- (a) as precluding the case-by-case review of the provision of care- (i) in individual incidents where the quality of care has significantly deviated from acceptable standards of practice; and (ii) with respect to a provider who has been determined to be an outlier; or (b) as precluding the case management of catastrophic, mental health, or substance abuse cases or long-term care where such management is necessary to achieve appropriate, cost-effective, and beneficial comprehensive medical care, as provided for in section 1104. subtitle f-health security budget; payments; cost containment measures part i-budgeting and payments to states sec. 1501. national health security budget.

(a) national health security budget.- (1) in general.-by not later than september 1 before the beginning of each year (beginning with 2010), the board shall establish a national health security budget, which- (a) specifies the total expenditures (including expenditures for administrative costs) to be made by the federal government and the states for covered health care services under this title; and (b) allocates those expenditures among the states consistent with section 1504. pursuant to subsection (b), such budget for a year shall not exceed the budget for the preceding year increased by the percentage increase in gross domestic product. (2) division of budget into components.-the national health security budget shall consist of at least 4 components: (a) a component for quality assessment activities (described in subtitle e). (b) a component for health professional education expenditures. (c) a component for administrative costs. (d) a component (in this

subtitle referred to as the "operating component") for operating and other expenditures not described in subparagraphs (a) through (c), consisting of amounts not included in the other components. a state may provide for the allocation of this component between capital expenditures and other expenditures. (3) allocation among components.-taking into account the state health security budgets established and submitted under section 1503, the board shall allocate the national health security budget among the components in a manner that- (a) assures a fair allocation for quality assessment activities (consistent with the national health security spending growth limit); and (b) assures that the health professional education expenditure component is sufficient to provide for the amount of health professional education expenditures sufficient to meet the need for covered health care services (consistent with the national health security spending growth limit under subsection (b)(2)). (b) basis for total expenditures.- (1) in general.-the total expenditures specified in such

budget shall be the sum of the capitation amounts computed under section 1502(a) and the amount of federal administrative expenditures needed to carry out this title. (2) national health security spending growth limit.-for purposes of this part, the national health security spending growth limit described in this paragraph for a year is (a) zero, or, if greater, (b) the average annual percentage increase in the gross domestic product (in current dollars) during the 3-year period beginning with the first quarter of the fourth previous year to the first quarter of the previous year minus the percentage increase (if any) in the number of eligible individuals residing in any state the united states from the first quarter of the second previous year to the first quarter of the previous year. (c) definitions.-in this title: (1) capital expenditures.-the term "capital expenditures" means expenses for the purchase, lease, construction, or renovation of capital facilities

and for equipment and includes return on equity capital. (2) health professional education expenditures.-the term "health professional education expenditures" means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities. sec. 1502. computation of individual and state capitation amounts. (a) capitation amounts.- (1) individual capitation amounts.-in establishing the national health security budget under section 1501(a) and in computing the national average per capita cost under subsection (b) for each year, the board shall establish a method for computing the capitation amount for each eligible individual residing in each state. the capitation amount for an eligible individual in a state classified within a risk group (established under subsection (d)(2)) is the product of- (a) a national average per capita cost for all covered

health care services (computed under subsection (b)); (b) the state adjustment factor (established under subsection (c)) for the state; and (c) the risk adjustment factor (established under subsection (d)) for the risk group. (2) state capitation amount.- (a) in general.-for purposes of this title, the term "state capitation amount" means, for a state for a year, the sum of the capitation amounts computed under paragraph (1) for all the residents of the state in the year, as estimated by the board before the beginning of the year involved. (b) use of statistical model.-the board may provide for the computation of state capitation amounts based on statistical models that fairly reflect the elements that comprise the state capitation amount described in subparagraph (a). (c) population information.-the bureau of the census shall assist the board in determining the number, place of residence, and risk group classification of eligible individuals. (b) computation of national

average per capita cost.- (1) for 2010.-for 2010, the national average per capita cost under this paragraph is equal to- (a) the average per capita health care expenditures in the united states in 2008 (as estimated by the board); (b) increased to 2009 by the board's estimate of the actual amount of such per capita expenditures during 2009; and (c) updated to 2010 by the national health security spending growth limit specified in section 1501(b)(2) for 2010. (2) for succeeding years.-for each succeeding year, the national average per capita cost under this subsection is equal to the national average per capita cost computed under this subsection for the previous year increased by the national health security spending growth limit (specified in section 1501(b)(2)) for the year involved. (c) state adjustment factors.- (1) in general.-subject to the succeeding paragraphs of this subsection, the board shall develop for each state a factor

to adjust the national average per capita costs to reflect differences between the state and the united states in- (a) average labor and nonlabor costs that are necessary to provide covered health services; (b) any social, environmental, or geographic condition affecting health status or the need for health care services, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); (c) the geographic distribution of the state's population, particularly the proportion of the population residing in medically underserved areas, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); and (d) any other factor relating to operating costs required to assure equitable distribution of funds among the states. (2) modification of health professional education component.-with respect to the portion of the national health security budget allocated to

expenditures for health professional education, the board shall modify the state adjustment factors so as to take into account- (a) differences among states in health professional education programs in operation as of the date of the enactment of this title; and (b) differences among states in their relative need for expenditures for health professional education, taking into account the health professional education expenditures proposed in state health security budgets under section 1503(a). (3) budget neutrality.-the state adjustment factors, as modified under paragraph (2), shall be applied under this subsection in a manner that results in neither an increase nor a decrease in the total amount of the federal contributions to all state health security programs under subsection (b) as a result of the application of such factors. (4) phase-in.-in applying state adjustment factors under this subsection during the 5-year period beginning with 2010, the board shall phase-in, over such

period, the use of factors described in paragraph (1) in a manner so that the adjustment factor for a state is based on a blend of such factors and a factor that reflects the relative actual average per capita costs of health services of the different states as of the time of enactment of this title. (5) periodic adjustment.-in establishing the national health security budget before the beginning of each year, the board shall provide for appropriate adjustments in the state adjustment factors under this subsection. (d) adjustments for risk group classification.- (1) in general.-the board shall develop an adjustment factor to the national average per capita costs computed under subsection (b) for individuals classified in each risk group (as designated under paragraph (2)) to reflect the difference between the average national average per capita costs and the national average per capita cost for individuals classified in the risk group. (2) risk groups.-the board shall

designate a series of risk groups, determined by age, health indicators, and other factors that represent distinct patterns of health care services utilization and costs. (3) periodic adjustment.-in establishing the national health security budget before the beginning of each year, the board shall provide for appropriate adjustments in the risk adjustment factors under this subsection. sec. 1503. state health security budgets. (a) establishment and submission of budgets.- (1) in general.-each state health security program shall establish and submit to the board for each year a proposed and a final state health security budget, which specifies the following: (a) the total expenditures (including expenditures for administrative costs) to be made under the program in the state for covered health care services under this title, consistent with subsection (b), broken down as follows: (i) by the 4 components

(described in section 1501(a)(2)), consistent with subsection (b). (ii) within the operating component- (i) expenditures for operating costs of hospitals and other facility-based services in the state; (ii) expenditures for payment to comprehensive health service organizations; (iii) expenditures for payment of services provided by health care practitioners; and (iv) expenditures for other covered items and services. amounts included in the operating component include amounts that may be used by providers for capital expenditures. (b) the total revenues required to meet the state health security expenditures. (2) proposed budget deadline.-the proposed budget for a year shall be submitted under paragraph (1) not later than june 1 before the year. (3) final budget.-the final budget for a year shall- (a) be established and submitted

under paragraph (1) not later than october 1 before the year, and (b) take into account the amounts established under the national health security budget under section 1501 for the year. (4) adjustment in allocations permitted.- (a) in general.-subject to subparagraphs (b) and (c), in the case of a final budget, a state may change the allocation of amounts among components. (b) notice.-no such change may be made unless the state has provided prior notice of the change to the board. (c) denial.-such a change may not be made if the board, within such time period as the board specifies, disapproves such change. (b) expenditure limits.- (1) in general.-the total expenditures specified in each state health security budget under subsection (a)(1) shall take into account federal contributions made under section 1504. (2) limit on claims processing

and billing expenditures.-each state health security budget shall provide that state administrative expenditures, including expenditures for claims processing and billing, shall not exceed 3 percent of the total expenditures under the state health security program, unless the board determines, on a case-by-case basis, that additional administrative expenditures would improve health care quality and cost effectiveness. (3) worker assistance.-a state health security program may provide that, for budgets for years before 2013, up to 1 percent of the budget may be used for purposes of programs providing assistance to workers who are currently performing functions in the administration of the health insurance system and who may experience economic dislocation as a result of the implementation of the program. (c) approval process for capital expenditures permitted.-nothing in this subtitle shall be

construed as preventing a state health security program from providing for a process for the approval of capital expenditures based on information derived from regional planning agencies. sec. 1504. federal payments to states. (a) in general.-each state with an approved state health security program is entitled to receive, from amounts in the american health security trust fund, on a monthly basis each year, of an amount equal to one-twelfth of the product of- (1) the state capitation amount (computed under section 1502(a)(2)) for the state for the year; and (2) the federal contribution percentage (established under subsection (b)). (b) federal contribution percentage.-the board shall establish a formula for the establishment of a federal contribution percentage for each state. such formula shall take into consideration a state's per capita income and revenue capacity and such other relevant

economic indicators as the board determines to be appropriate. in addition, during the 5-year period beginning with 2010, the board may provide for a transition adjustment to the formula in order to take into account current expenditures by the state (and local governments thereof) for health services covered under the state health security program. the weighted-average federal contribution percentage for all states shall equal 86 percent and in no event shall such percentage be less than 81 percent nor more than 91 percent. (c) use of payments.-all payments made under this section may only be used to carry out the state health security program. (d) effect of spending excess or surplus.- (1) spending excess.-if a state exceeds it's budget in a given year, the state shall continue to fund covered health services from its own revenues. (2) surplus.-if a state provides

all covered health services for less than the budgeted amount for a year, it may retain its federal payment for that year for uses consistent with this title. sec. 1505. account for health professional education expenditures. (a) separate account.-each state health security program shall- (1) include a separate account for health professional education expenditures; and (2) specify the general manner, consistent with subsection (b), in which such expenditures are to be distributed among different types of institutions and the different areas of the state. (b) distribution rules.-the distribution of funds from the account must take into account the potentially higher costs of placing health professional students in clinical education programs in health professional shortage areas. part ii-payments by states to providers sec. 1510. payments to hospitals

and other facility-based services for operating expenses on the basis of approved global budgets. (a) direct payment under global budget.-payment for operating expenses for institutional and facility-based care, including hospital services and nursing facility services, under state health security programs shall be made directly to each institution or facility by each state health security program under an annual prospective global budget approved under the program. such a budget shall include payment for outpatient care and non-facility-based care that is furnished by or through the facility. in the case of a hospital that is wholly owned (or controlled) by a comprehensive health service organization that is paid under section 1513 on the basis of a global budget, the global budget of the organization shall include the budget for the hospital. (b) annual negotiations; budget approval.-

(1) in general.-the prospective global budget for an institution or facility shall- (a) be developed through annual negotiations between- (i) a panel of individuals who are appointed by the governor of the state and who represent consumers, labor, business, and the state government; and (ii) the institution or facility; and (b) be based on a nationally uniform system of cost accounting established under standards of the board. (2) considerations.-in developing a budget through negotiations, there shall be taken into account at least the following: (a) with respect to inpatient hospital services, the number, and classification by diagnosis-related group, of discharges. (b) an institution's or facility's past expenditures. (c) the extent to which debt service for capital expenditures has been included in the proposed operating budget. (d) the extent to which capital expenditures are financed

directly or indirectly through reductions in direct care to patients, including (but not limited to) reductions in registered nursing staffing patterns or changes in emergency room or primary care services or availability. (e) change in the consumer price index and other price indices. (f) the cost of reasonable compensation to health care practitioners. (g) the compensation level of the institution's or facility's work force. (h) the extent to which the institution or facility is providing health care services to meet the needs of residents in the area served by the institution or facility, including the institution's or facility's occupancy level. (i) the institution's or facility's previous financial and clinical performance, based on utilization and outcomes data provided under this title. (j) the type of institution or facility, including whether the institution or facility is part

of a clinical education program or serves a health professional education, research or other training purpose. (k) technological advances or changes. (l) costs of the institution or facility associated with meeting federal and state regulations. (m) the costs associated with necessary public outreach activities. (n) in the case of a for-profit facility, a reasonable rate of return on equity capital, independent of those operating expenses necessary to fulfill the objectives of this title. (o) incentives to facilities that maintain costs below previous reasonable budgeted levels without reducing the care provided. (p) with respect to facilities that provide mental health services and substance abuse treatment services, any additional costs involved in the treatment of dually diagnosed individuals. the portion of such a budget that relates to expenditures for

health professional education shall be consistent with the state health security budget for such expenditures. (3) provision of required information; diagnosis-related group.-no budget for an institution or facility for a year may be approved unless the institution or facility has submitted on a timely basis to the state health security program such information as the program or the board shall specify, including in the case of hospitals information on discharges classified by diagnosis-related group. (c) adjustments in approved budgets.- (1) adjustments to global budgets that contract with comprehensive health service organizations.-each state health security program shall develop an administrative mechanism for reducing operating funds to institutions or facilities in proportion to payments made to such institutions or facilities for services contracted for by a comprehensive health service

organization. (2) amendments.-in accordance with standards established by the board, an operating and capital budget approved under this section for a year may be amended before, during, or after the year if there is a substantial change in any of the factors relevant to budget approval. (d) donations permissible.-the states health security programs may permit institutions and facilities to raise funds from private sources to pay for newly constructed facilities, major renovations, and equipment. the expenditure of such funds, whether for operating or capital expenditures, does not obligate the state health security program to provide for continued support for such expenditures unless included in an approved global budget. sec. 1511. payments to health care practitioners based on prospective fee schedule. (a) fee for service.- (1) in general.-every independent health care

practitioner is entitled to be paid, for the provision of covered health services under the state health security program, a fee for each billable covered service. (2) global fee payment methodologies.-the board shall establish models and encourage state health security programs to implement alternative payment methodologies that incorporate global fees for related services (such as all outpatient procedures for treatment of a condition) or for a basic group of services (such as primary care services) furnished to an individual over a period of time, in order to encourage continuity and efficiency in the provision of services. such methodologies shall be designed to ensure a high quality of care. (3) billing deadlines; electronic billing.-a state health security program may deny payment for any service of an independent health care practitioner for which it did not receive a bill and appropriate supporting documentation (which had been previously specified) within 30

days after the date the service was provided. such a program may require that bills for services for which payment may be made under this section, or for any class of such services, be submitted electronically. (b) payment rates based on negotiated prospective fee schedules.-with respect to any payment method for a class of services of practitioners, the state health security program shall establish, on a prospective basis, a payment schedule. the state health security program may establish such a schedule after negotiations with organizations representing the practitioners involved. such fee schedules shall be designed to provide incentives for practitioners to choose primary care medicine, including general internal medicine and pediatrics, over medical specialization. nothing in this section shall be construed as preventing a state from adjusting the payment schedule amounts on a quarterly or other periodic basis depending on whether

expenditures under the schedule will exceed the budgeted amount with respect to such expenditures. (c) billable covered service defined.-in this section, the term "billable covered service" means a service covered under section 1101 for which a practitioner is entitled to compensation by payment of a fee determined under this section. sec. 1512. payments to comprehensive health service organizations. (a) in general.-payment under a state health security program to a comprehensive health service organization to its enrollees shall be determined by the state- (1) based on a global budget described in section 1510; or (2) based on the basic capitation amount described in subsection (b) for each of its enrollees. (b) basic capitation amount.- (1) in general.-the basic capitation amount described in this subsection for an enrollee shall be determined by the state

health security program on the basis of the average amount of expenditures that is estimated would be made under the state health security program for covered health care services for an enrollee, based on actuarial characteristics (as defined by the state health security program). (2) adjustment for special health needs.-the state health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the organization. (3) adjustment for services not provided.-the state health security program shall adjust such average amounts to take into account the cost of covered health care services that are not provided by the comprehensive health service organization under section 1203(a). sec. 1513. payments for community-based primary health services.

(a) in general.-in the case of community-based primary health services, subject to subsection (b), payments under a state health security program shall- (1) be based on a global budget described in section 1510; (2) be based on the basic primary care capitation amount described in subsection (c) for each individual enrolled with the provider of such services; or (3) be made on a fee-for-service basis under section 1511. (b) payment adjustment.-payments under subsection (a) may include, consistent with the budgets developed under this title- (1) an additional amount, as set by the state health security program, to cover the costs incurred by a provider which serves persons not covered by this title whose health care is essential to overall community health and the control of communicable disease, and for whom the cost of such care is otherwise uncompensated; (2) an additional amount, as set by the state health security program, to cover the reasonable

costs incurred by a provider that furnishes case management services (as defined in section 1915(g)(2) of the social security act), transportation services, and translation services; and (3) an additional amount, as set by the state health security program, to cover the costs incurred by a provider in conducting health professional education programs in connection with the provision of such services. (c) basic primary care capitation amount.- (1) in general.-the basic primary care capitation amount described in this subsection for an enrollee with a provider of community-based primary health services shall be determined by the state health security program on the basis of the average amount of expenditures that is estimated would be made under the state health security program for such an enrollee, based on actuarial characteristics (as defined by the state health security program). (2) adjustment for special

health needs.-the state health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the provider. (3) adjustment for services not provided.-the state health security program shall adjust such average amounts to take into account the cost of community-based primary health services that are not provided by the provider. (d) community-based primary health services defined.-in this section, the term "community-based primary health services" has the meaning given such term in section 1102(a). sec. 1514. payments for prescription drugs. (a) establishment of list.- (1) in general.-the board shall establish a list of approved prescription drugs and biologicals that the board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for

coverage under this title. (2) exclusions.-the board may exclude reimbursement under this title for ineffective, unsafe, or over-priced products where better alternatives are determined to be available. (b) prices.-for each such listed prescription drug or biological covered under this title, for insulin, and for medical foods, the board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this title as the cost of a drug to a provider thereof. the board may conduct negotiations, on behalf of state health security programs, with product manufacturers and distributors in determining the applicable product price or prices. (c) charges by independent pharmacies.-each state health security program shall provide for payment for a prescription drug or biological or insulin furnished by an independent pharmacy based on the drug's

cost to the pharmacy (not in excess of the applicable product price established under subsection (b)) plus a dispensing fee. in accordance with standards established by the board, each state health security program, after consultation with representatives of the pharmaceutical profession, shall establish schedules of dispensing fees, designed to afford reasonable compensation to independent pharmacies after taking into account variations in their cost of operation resulting from regional differences, differences in the volume of prescription drugs dispensed, differences in services provided, the need to maintain expenditures within the budgets established under this title, and other relevant factors. sec. 1515. payments for approved devices and equipment. (a) establishment of list.-the board shall establish a list of approved durable medical equipment and therapeutic devices and equipment (including

eyeglasses, hearing aids, and prosthetic appliances), that the board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for coverage under this title. (b) considerations and conditions.-in establishing the list under subsection (a), the board shall take into consideration the efficacy, safety, and cost of each item contained on such list, and shall attach to any item such conditions as the board determines appropriate with respect to the circumstances under which, or the frequency with which, the item may be prescribed. (c) prices.-for each such listed item covered under this title, the board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this title as the cost of the item to a provider thereof. the board may conduct negotiations, on behalf of state health security programs, with equipment and device manufacturers and distributors

in determining the applicable product price or prices. (d) exclusions.-the board may exclude from coverage under this title ineffective, unsafe, or overpriced products where better alternatives are determined to be available. sec. 1516. payments for other items and services. in the case of payment for other covered health services, the amount of payment under a state health security program shall be established by the program- (1) in accordance with payment methodologies which are specified by the board, after consultation with the american health security advisory council, or methodologies established by the state under section 1519; and (2) consistent with the state health security budget. sec. 1517. payment incentives for medically underserved areas. (a) model payment methodologies.-in addition to the payment amounts otherwise provided in this title, the board shall establish model

payment methodologies and other incentives that promote the provision of covered health care services in medically underserved areas, particularly in rural and inner-city underserved areas. state health security programs to increase payment amounts or otherwise provide additional incentives, consistent with the state health security budget, to encourage the provision of medically necessary and appropriate services in underserved areas. sec. 1518. authority for alternative payment methodologies. a state health security program, as part of its plan under section 1304(a), may use a payment methodology other than a methodology required under this part so long as- (1) such payment methodology does not affect the entitlement of individuals to coverage, the weighting of fee schedules to encourage an increase in the number of primary care providers, the ability of

individuals to choose among qualified providers, the benefits covered under the program, or the compliance of the program with the state health security budget under part i; and (2) the program submits periodic reports to the board showing the operation and effectiveness of the alternative methodology, in order for the board to evaluate the appropriateness of applying the alternative methodology to other states. part iii-mandatory assignment and administrative provisions sec. 1520. mandatory assignment. (a) no balance billing.-payments for benefits under this title shall constitute payment in full for such benefits and the entity furnishing an item or service for which payment is made under this title shall accept such payment as payment in full for the item or service and may not accept any payment or impose any charge for any such item or service other than accepting payment from the state health

security program in accordance with this title. (b) enforcement.-if an entity knowingly and willfully bills for an item or service or accepts payment in violation of subsection (a), the board may apply sanctions against the entity in the same manner as sanctions could have been imposed under section 1842(j)(2) of the social security act for a violation of section 1842(j)(1) of such act. such sanctions are in addition to any sanctions that a state may impose under its state health security program. sec. 1521. procedures for reimbursement; appeals. (a) procedures for reimbursement.-in accordance with standards issued by the board, a state health security program shall establish a timely and administratively simple procedure to assure payment within 60 days of the date of submission of clean claims by providers under this title. (b) appeals process.-each state health security program shall establish an appeals process to

handle all grievances pertaining to payment to providers under this title. subtitle g-financing provisions; providers under this title. (b) appeals process.-each state health security program shall establish an appeals process to

establish an appeals process to handle all grievances pertaining to payment to providers under this title. subtitle g-financing provisions; american health security trust fund sec. 1530. amendment of 1986 code; section 15 not to apply. (a) amendment of 1986 code.-except as otherwise expressly provided, whenever in this subtitle an amendment or repeal is expressed in terms of an amendment to, or repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of the internal revenue code of 1986. (b) section 15 not to apply.-the amendments made by part ii shall not be treated as a change in a rate of tax for purposes of section 15 of the internal revenue code of 1986.

part i-american health security trust fund sec. 1531. american health security trust fund. (a) in general.-there is hereby created on the books of the treasury of the united states a trust fund to be known as the american health security trust fund (in this section referred to as the "trust fund"). the trust fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in, or appropriated to, such trust fund as provided in this title. (b) appropriations into trust fund.- (1) taxes.-there are hereby appropriated to the trust fund for each fiscal year (beginning with fiscal year 2011), out of any moneys in the treasury not otherwise appropriated, amounts equivalent to 100 percent of the aggregate increase in tax liabilities under the internal revenue code of 1986 which is attributable to the application of the amendments made by this subtitle. the amounts appropriated by the preceding sentence shall be transferred

from time to time (but not less frequently than monthly) from the general fund in the treasury to the trust fund, such amounts to be determined on the basis of estimates by the secretary of the treasury of the taxes paid to or deposited into the treasury; and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the amounts that should have been so transferred. (2) current program receipts.-notwithstanding any other provision of law, there are hereby appropriated to the trust fund for each fiscal year (beginning with fiscal year 2011) the amounts that would otherwise have been appropriated to carry out the following programs: (a) the medicare program, under parts a, b, and d of title xviii of the social security act (other than amounts attributable to any premiums under such parts). (b) the medicaid program, under state plans approved under title xix of such act. (c) the federal employees health benefit program, under chapter 89 of title 5, united states

code. (d) the tricare program (formerly known as the champus program), under chapter 55 of title 10, united states code. (e) the maternal and child health program (under title v of the social security act), vocational rehabilitation programs, programs for drug abuse and mental health services under the public health service act, programs providing general hospital or medical assistance, and any other federal program identified by the board, in consultation with the secretary of the treasury, to the extent the programs provide for payment for health services the payment of which may be made under this title. (c) incorporation of provisions.-the provisions of subsections (b) through (i) of section 1817 of the social security act shall apply to the trust fund under this title in the same manner as they applied to the federal hospital insurance trust fund under part a of title xviii of such act, except that the american health security standards board shall

constitute the board of trustees of the trust fund. (d) transfer of funds.-any amounts remaining in the federal hospital insurance trust fund or the federal supplementary medical insurance trust fund after the settlement of claims for payments under title xviii have been completed, shall be transferred into the american health security trust fund. part ii-taxes based on income and wages sec. 1535. payroll tax on employers. (a) in general.-section 3111 (relating to tax on employers) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection: "(c) health care.-in addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the wages (as defined in section 3121(a)) paid by him with respect to employment (as defined in section 3121(b)).".

(b) self-employment income.-section 1401 (relating to rate of tax on self-employment income) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection: "(c) health care.-in addition to other taxes, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 8.7 percent of the amount of the self-employment income for such taxable year.". (c) comparable taxes for railroad services.- (1) tax on employers.-section 3221 is amended by redesignating subsection (c) as subsections (d) and inserting after subsection (b) the following new subsection: "(c) health care.-in addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the compensation paid by such employer for services rendered to such employer.". (2) tax on employee

representatives.-section 3211 (relating to tax on employee representatives) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new paragraph: "(c) health care.-in addition to other taxes, there is hereby imposed on the income of each employee representative a tax equal to 8.7 percent of the compensation received during the calendar year by such employee representative for services rendered by such employee representative.". (3) no applicable base.-subparagraph (a) of section 3231(e)(2) is amended by adding at the end thereof the following new clause: "(iv) health care taxes.-clause (i) shall not apply to the taxes imposed by sections 3221(c) and 3211(c).". (4) technical amendment.- (a) subsection (d) of section 3211, as redesignated by paragraph (2), is amended by striking "and (b)" and inserting ", (b), and (c)".

(b) subsection (d) of section 3221, as redesignated by paragraph (1), is amended by striking "and (b)" and inserting ", (b), and (c)". (d) effective date.-the amendments made by this section shall apply to remuneration paid after december 31, 2010. sec. 1536. health care income tax. (a) general rule.-subchapter a of chapter 1 (relating to determination of tax liability) is amended by adding at the end thereof the following new part: "part viii-health care income tax on individuals "sec. 59b. health care income tax. "(a) imposition of tax.-in the case of an individual, there is hereby imposed a tax (in addition to any other tax imposed by this subtitle) equal to 2.2 percent of the taxable income of the taxpayer for the taxable year.

"(b) no credits against tax; no effect on minimum tax.-the tax imposed by this section shall not be treated as a tax imposed by this chapter for purposes of determining- "(1) the amount of any credit allowable under this chapter, or "(2) the amount of the minimum tax imposed by section 55. "(c) special rules.- "(1) tax to be withheld, etc.-for purposes of this title, the tax imposed by this section shall be treated as imposed by section 1. "(2) reimbursement of tax by employer not includible in gross income.-the gross income of an employee shall not include any payment by his employer to reimburse the employee for the tax paid by the employee under this section. "(3) other rules.-the rules of section 59a(d) shall apply to the tax imposed by this section.". (b) clerical amendment.-the table of parts for subchapter a of chapter 1 is amended by

adding at the end the following new item: (c) effective date.-the amendments made by this section shall apply to taxable years beginning after december 31, 2010. subtitle h-conforming amendments to the employee retirement income security act of 1974 sec. 1601. erisa inapplicable to health coverage arrangements under state health security programs. section 4 of the employee retirement income security act of 1974 (29 u.s.c. 1003) is amended- (1) in subsection (a), by striking "(b) or (c)" and inserting "(b), (c), or (d)"; and (2) by adding at the end the following new subsection: "(d) the provisions of this title shall not apply to any arrangement forming a part of a state health security program established pursuant to section 1001(b) of the american health

security act of 2009.". sec. 1602. exemption of state health security programs from erisa preemption. section 514(b) of the employee retirement income security act of 1974 (29 u.s.c. 1144(b)) (as amended by sections 174(b)(3)(b) and 182(b) of this title) is amended by adding at the end the following new paragraph: "(8) subsection (a) of this section shall not apply to state health security programs established pursuant to section 1001(b) of the american health security act of 2009.". sec. 1603. prohibition of employee benefits duplicative of benefits under state health security programs; coordination in case of workers' compensation. (a) in general.-part 5 of subtitle b of title i of the employee retirement income security act of 1974 is amended by adding at the end the following new section: "prohibition of employee

benefits duplicative of state health security program benefits; coordination in case of workers' compensation "sec. 519. (a) subject to subsection (b), no employee benefit plan may provide benefits which duplicate payment for any items or services for which payment may be made under a state health security program established pursuant to section 1001(b) of the american health security act of 2009. "(b) (1) each workers compensation carrier that is liable for payment for workers compensation services furnished in a state shall reimburse the state health security plan for the state in which the services are furnished for the cost of such services. "(2) in this subsection: "(a) the term 'workers compensation carrier' means an insurance company that underwrites workers compensation medical benefits with respect to 1 or more employers and includes an employer or fund that is

financially at risk for the provision of workers compensation medical benefits. "(b) the term 'workers compensation medical benefits' means, with respect to an enrollee who is an employee subject to the workers compensation laws of a state, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee. "(c) the term 'workers compensation services' means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term-care services) commonly used for treatment of work-related injuries and illnesses.". (b) conforming amendment.-section 4(b) of such act (29 u.s.c. 1003(b)) is amended by adding at the end the following: "paragraph (3) shall apply subject to section 519(b) (relating to reimbursement of state health security plans by workers compensation carriers).".

(c) clerical amendment.-the table of contents in section 1 of such act is amended by inserting after the item relating to section 518 the following new items: "sec. 519. prohibition of employee benefits duplicative of state health security program benefits; coordination in case of workers' compensation.". sec. 1604. repeal of continuation coverage requirements under erisa and certain other requirements relating to group health plans. (a) in general.-part 6 of subtitle b of title i of the employee retirement income security act of 1974 (29 u.s.c. 1161 et seq.) is repealed. (b) conforming amendments.- (1) section 502(a) of such act (29 u.s.c. 1132(a)) is amended- (a) by striking paragraph (7); and (b) by redesignating paragraphs (8), (9), and (10) as paragraphs (7), (8), and (9), respectively. (2) section 502(c)(1) of such

act (29 u.s.c. 1132(c)(1)) is amended by striking "paragraph (1) or (4) of section 606,". (3) section 514(b) of such act (29 u.s.c. 1144(b)) is amended- (a) in paragraph (7), by striking "section 206(d)(3)(b)(i))," and all that follows and inserting "section 206(d)(3)(b)(i))."; and (b) by striking paragraph (8). (4) the table of contents in section 1 of the employee retirement income security act of 1974 is amended by striking the items relating to part 6 of subtitle b of title i of such act. sec. 1605. effective date of subtitle. the amendments made by this subtitle shall take effect january 1, 2012. subtitle i-additional conforming amendments sec. 1701. repeal of certain provisions in internal revenue code of 1986. the provisions of titles iii and iv of the health insurance portability and accountability act of 1996, other than

subtitles d and h of title iii and section 342, are repealed and the provisions of law that were amended or repealed by such provisions are hereby restored as if such provisions had not been enacted. sec. 1702. repeal of certain provisions in the employee retirement income security act of 1974. ufrz. mr. sanders: mr. president? the presiding officer: the senator from vermont. mr. sanders: i withdraw my amendment. a senator: regular order, mr. president. the presiding officer: the senator has that right. the amendment is withdrawn. mr. sanders: mr. president, pursuant to the 30-minutes -- the presiding officer: under the previous order, the senator from vermont is recognized for 30 minutes. mr. sanders: mr. president, let me begin not by talking about my amendment, but by talking about republican action right here on the floor of the

senate. everybody in this country understands that our nation faces a significant number of major crises, whether it's the disintegration of our health care system, the fact that 17% of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we've got two wars, we've got global warming, we have a $12 trillion national debt. and the best the republicans can do is try to bring the united states government to a halt by forcing a reading of a 7 hundred-page amendment -- 7 hundred-page amendment. that is an outrage. people can have honest disagreements, but in this moment of crisis it is wrong to bring the united states government to a halt. now, mr. president, i'm very disturbed that i'm unable to bring the amendment that i wanted to bring to the floor of the senate dealing with a medicare for all single-payer

program. i want to thank senator reid for allowing me to try to bring this amendment to the floor before it was obstructed to and delayed and prevented by the republican leadership. but i did want to mention that this legislation is cosponsored by senator sherrod brown and roland burris. and i was more than aware and very proud that this amendment would have been the first time in american history that a medicare for all single-payer bill was brought before a floor of congress. i was more than aware that that amendment would not win. i knew that. but i am absolutely convinced that this legislation or legislation like it will

eventually become the law of the land. and the reason for my -- my optimism that a medicare for all single-payer bill will eventually prevail is that that will be and is the only mechanism we have to provide comprehensive, high-quality health care to all of our people in a cost-effective way. because it is the only approach which eliminates the hundreds of billions of dollars in waste, administrative costs, bureaucracy and profiteering that is engendered by the private insurance companies, and that is the simple truth. we are not going to provide comprehensive, universal cost-effective health care to all of our people without eliminating the hundreds of billions of dollars in bureaucratic waste an profiteering that -- an

profiteering that currently takes place and is engendered by the private insurance companies. the day will come, although i recognize it is not today, when the united states congress will have the courage to stand up to the private insurance companies and the drug companies and the medical equipment suppliers and all of those who profit and make billions of dollars every single year off of human sick necessary. and on that day when it comes, and it will come, the united states congress will finally proclaim that health care is a right of all people and not just a privilege. and that day will come, as surely as i constant here today. madam president, there are those who think that medicare for all is some kind of a fringe idea. just a few, you know, left-wing

folks out there think that this is the way to go. but let me assure that you that this is absolutely not the case. the single-payer concept has widespread support all across this country. in a 2007a.p.-yahoo poll, 65% of respondents said that the u.s. should adopt a universal health care program where everyone is covered by a program like medicare that is run by the government and financed by taxpayers. madam president, there is also widespread support for medicare for all approach among those people who understand this issue the most, and that is the medical community. and that support goes well beyond the 17,000 doctors in the physicians for national health care program who are fighting every day for a single-payer

system. it goes beyond the california nurses association, the largest nurses union in the country, who are also fighting for a single-payer system. madam president, in march of 2008, a survey of 2,000 american doctors published in the internal medicine confirmed that 59% of physicians -- quote -- "supported legislation to establish national health insurance." end of quote. and, madam president, you would be particularly interested to know that the new hampshire medical society surveyed new hampshire physicians and found and i quote -- "two-thirds of new hampshire physicians, including 81% of primary care clinicians would prefer a single payer system where collection of taxes were used to meet the basic health care needs of all

citizens. end of quote. that's new hatch environment in 2007, "minnesota medicine" magazine surveyed minnesota physicians and found that 54% preferred a single-payer system. 86% of physicians agree that it is the responsibility of society through the government to ensure that everyone has access to good medical care. end of quote. but it is not just doctors. it is not just nurses, it is not just millions of ordinary americans. what we are seeing now is that national state and local organizations representing a wide variety of regions and interests support single payer. these include the u.s. conference of mayors. u.s. conference of mayors, the american medical students association, the afl-cio, the national association for the advancement of colored people, the national association of letter carriers, the national

education association, the united church of christ, the u.a.w., the united steel workers, united electrical workers and older american league -- older women's league. there are so many other organizations that i will not take the time to list, but i with would ask, madam president, unanimous consent that i can submit a list to the desk of all of the organization representing millions and millions of americans who are sick and tired of the current system and want to move to a medicare for all single payer system. the presiding officer: without objection. mr. sanders: thank you. madam president, there is something significant support in the house of representatives for a single-payer system. together h.r. 6676 and h.r. 1200, two different single payer programs have 94 cosponsors. let me say a word about state

legislators who have moved toward a single payer system. in california, our largest state, the state legislature there on two occasions passed a single-payer program. largest state in america passed a single-payer program and on both occasion it was vetoed by the governor. in new york state, the state assembly passed a single-payer system. among other systems where single payer has been proposed and discussed, ohio, massachusetts, georgia, colorado, maine, vermont, wisconsin, oregon, washington, minnesota, indiana, and new hampshire. madam president, why is it that we need an entirely new approach for health care in this country? why is it? and the answer, i think, is pretty obvious. our current system, dominated by profit-making insurance companies, simply does not work.

yes, we have to confess, it does work for the insurance company, who make huge profits and provide their c.e.o.'s with extravagant compensation packages. yes, it does work and we saw how well it worked yesterday right here on the floor for the pharmaceutical industry, which year after year leads almost every other industry in profits while charging the american people by far -- not even close -- the highest prices in the world for prescription drugs. so it works for the insurance companies. it works for the drug companies. it works for the medical equipment suppliers. and many other people who are making billions of dollars off of our health care system. but, madam president, it is not working. in fact, it is failing for ordinary americans. today 46 million people in our country have no health insurance

and even more are underinsured with high deductibles or co-payments. today as our primary health care system collapses, tens of millions of americans do not have access to a doctor on a regular basis. and, tragically, madam president, some 45,000 of our fellow americans who do not have access to a doctor on a regular basis die every single year. that is 15 times more americans die of preventible diseases than were murdered in the horrific 9/11 attack against our country. and that takes place every year. 45,000 people. this is not acceptable. this is a manifestation of a collapsing system that needs fundamental change. madam president, a number of months ago i took to the floor

to relate stories that i heard from people throughout the state of vermont regarding the health care crisis. stories which i published into a small booklet and placed on my website. and let me just tell you one story. a man from swanton, vermont, in the northern part of our state, wrote to me to tell me the story of his younger brother, a vietnam veteran, who died three weeks after being diagnosed with colon cancer. at the time he was diagnosed, he had been laid off from his job and could not afford cobra coverage. in quote this is what his brother said, "when he was in enough pain to see a doctor -- when he was in enough pain to see a doctor, it was too late. he left a wife and two teenaged sons in the prime of his life at 50 years old. the attending physician said that if had only sought treatment earlier, he would still be alive."

whhorrifically, tragically, that story is told in in country over and over again, if only he had gone to the doctor in time, he could have lived, but didn't have any health insurance. that should not be taking place in the united states of america in the year 2009. and the problem extends beyond even the thousands who die every single year needlessly. many, many others suffer needless disability, strokes that leave them paralyzed because they couldn't afford treatment for their high blood pressure or amputations, blindness or kidney failure from under treated diabetes. infants are born disabled because their mothers couldn't get the kind of prenatal care that any mother should have. an millions with mental illness go untreated today.

in a town in northern vermont, not far from where i live, a physician told me that one-third of the patients that she treats are unable to pay for the prescription drugs that she prescribes. think about the insanity of that. we ask doctors to diagnose our illness, to help us out the. she write as prescription drug. one-third of her patients cannot afford to fill that prescription. that is insane. that is a crumbling health care system. and the reason people can't afford to fill their prescription drugs is our people because the pharmaceutical industry greed are forced to pay, by far, the highest prices in the world for prescription drugs. this is indefensible. there is nobody who can come to the floor of this senate and tell me that that makes one shred of sense. madam president, the disintegration of our health

care system causes not only unnecessary human pain, suffering, and death. but it is also an economic disaster, an economic disaster. talk to small businesses in vermont and new hampshire, any place in this country, and they tell you that they cannot afford to invest in their companies and create new jobs because all of their profits are going to soaring health care costs, 10%, 15%, 20% a year. talk to the recently bankrupt general motors, and they will tell you they spend more money per automobile on health care than they do on steel and in the international competition that they are engaged in. they are forced to pay $1,500 per car on health care while mercedes and germany spends $419 and toyota and japan spend $97. try and compete against this that.

-- against that. further from an economic perspective, it is beyond comprehension that of the nearly one million people who will file for bankruptcy this year, the vast majority of those people are filing for bankruptcy because of medically related illnesses. further, from an emotional point of view, let's just take a deep breath and think about millions of people who are today struggling with cancer, struggling with haar disease or other chronic illnesses. and you know what? they are not even able to focus on their disease, trying to get well. they're summoning half of their energy to fight with the insurance companies to make sure that they get the coverage that they need. that is not civilized. that is not worthy of the united states of america. madam president, in my state of

vermont, which i expect is quite similar to new hampshire and every other state in this country, we have all walked in to small mom-and-pop stores and we have seen those little donation jars that says, help out this or that family because the breadwinner in that family is struggling with cancer and does not have any health insurance, or little sally needs some kind of operation and she doesn't have any health insurance. put in a buck or five bucks to help that family get the health care that they need. this is the united states of america. this should not and cannot be allowed to continue. madam president, one of the unfortunate things that has occurred during the entire health care debate that we are in right now is that we have largely ignored what is happening in terms of health care around the rest of the wrld. i havworld.

i have heard some of my republican colleagues stand up and say, "we have the best health care system in the world." yeah, we do if you're a millionaire or billionaire. but not if you're in the middle class, certainly if you're a working-class person. it's just not true. today in the united states, despite 46 million being uninsured and more underinsured, spends twice as much per person than any other country. and despite that, our health care outcomes are in many respects -- not all but in many respects -- worse than other countries in terms of life expectancy. other countries have longer life expectancy than we do. they're better in infant mortality, and they do a lot better job in terms of preventable deaths. it seems to me that the very beginning of this debate we should have asked a very, very simple question. and that is: why is it we are spending twice as much per

person on health care than any other country with outcomes that in many respects are not as good? madam president, according to an oecd report in 2007, the united states -- and this is what this chart is about -- the united states spent $7,290, over $7,000 per person on health care. canada spent $3,896 -- $3,895, almost half of what we spent. france spent $3,601 -- less than half of what we spent. the united kingdom spent less than $3,000, and italy spent $2,600 compared to the more than $7,000 we spent. now, don't you think that maybe the first question that we might have asked is why is it that we've spent so much and yet our health care outcomes are in respects are worse than other

countries? now, why is it that that happens? well, let me tell you what other people resident going to tell you. and that is one of the key issues that needed to be debated in this health care discussion which has not been discussed. and the reason and the simple reason as to why we spend so much more than any other country with outcomes that are not as good as many other countries, is that this legislation from the very beginning started with the assumption that we need to contain the privacy of private, for-profit health insurance companies. and that reality, that basic reality that we cannot touch private insurance companies -- in fact, that we've got to dump millions more people into private health insurance companies, that was an issue that could not be even discuss discussed. sadly, despite all the money that we spent, we get poor value

from our investment. according to the world health wh organization, the united states ranks 37th in herms of health performance, compared with five other countries, canada, united kingdom, new zealand and others. sometimes these groups poll people. they go over the world and they poll people in the country and they say, well, how do you feel about your own health care system? and we end up way, way down below, behind other countries. you know, recently, while the canadian health care system was being attacked every single day, they did a poll in canada. and they said to the canadian people, you know, what do about your health care system? people in america say you've got a terrible system. do you want to junk your system and adopt the american system? by overwhelming numbers -- overwhelming numbers -- the people of canada said, thank you, no thank you, we know the

american system. we will stay with our system. i was in the united kingdom a couple of months ago and it was an interesting experience. it was a parliamentarian meeting and i met with a number of people in the conservative party. not the labor party, not the liberal democratic party, the conservative party, the party which likely will become the government of that country. and the conservatives were outraged by the kind of attacks being leveled against the national health system in their country, the lies that were being told about their system. and, in fact, the leader of the conservative party got up to defend the national health system in the united kingdom and said, if we come to power, we will defend the united -- the national health system. those are the conservatives. madam president, what is the problem with our system which

makes it radically different than the system in any other industrialized country? and it is that we have allowed for-profit private corporations to develop and run our health care system and the system that these companies have developed is the most costly, wasteful, complicated and bureaucratic in the entire world. everybody knows that. with 1,300 private insurance companies and thousands and thousands of different health benefit programs all designed to maximize profits, private health insurance companies spend an incredible 30% -- 30% -- of every health care da dollar on administration and billing, on exorbitant c.e.o. compensation packages, on advertising,

lobbying and campaign contributions. this amounts to some $350 billion every single year that is not spent on health care but is spent on wasteful bureaucracy. it is spent on bureaucrats at an insurance company telling us why we can't get the insurance we paid for. and how many people today are on the phone arguing with insurance companies about trying to get the benefits that they paid for? it is spent on staff in a physician's office who spend all of their time submitting claims. they're not treating people, they're submitting claims. it is spent on hundreds of people working in the basement of hospitals who are not delivering babies, they're not treaty people with cancer, they're not making people well, they are sending out bills. that's what we do of, we send out bills. and we spend hundreds of billions of dollars doing that rather than bringing primary

health care physicians into rural areas rather than getting the dentist that we need, rather than getting the nurses that we need. madam president, let me just give you a few outrageous examples. wfer unknows that this country is -- everyone knows that this country is in the midst of a major crisis in primary health care. we lack doctors, we lack nurses, we lack dentists. a major, major crisis getting worse every single day. yet, while we are unable to produce those desperately needed doctors and nurses and dentists, we are producing legions -- legions -- of insurance company bureaucrats. and here is a chart which deals with that issue. what this chart shows is that over the last three decades, the number of administrative personnel, bureaucrats who do nothing to cure our illnesses or keep us well, the number of bureaucrats has grown by 25

times the number of physicians. this is insurance growth, nonexistence. this is health care bureaucrats on the phone today telling you why you can't get the health care coverage you paid for or telling you that you have a preexisting condition or throwing you off of health care because you committed the crime last year of getting sick. this is where our health care dollars are going and that is why we need a single-payer system. according to dr. huey rinehart -- let me give you another example -- in testimony before congress, duke university hospital, a very fine hospital, has almost 900 billing dloarks o deal with hundreds of distinct managed care contracts. do you know how many beds they have in the hospital? they've got 900 beds and they've got 900 bureaucrats involved in billing for the 900 beds. tell me that that makes sense. madam president, at a time when

the middle class is collapsing and when millions of americans are unable to afford health insurance, health premiums are soaring, as are the profits of health insurance companies. from 2003-2007, the combined profits of the nation's major health insurance companies increased by 170%. and while more and more americans are losing their jobs, the top executives in the industry are receiving lavish compensation packages. in 2007, despite plans to cut 3% to 4% of their work force, johnson&johnson found the cash to pay its c.e.o., bill well we willdone, $31.5. bill williams of aetna took openly $31 million, and the head of cigna, bill hathaway took openly $27 million. let me describe the mother of

all features. and this is -- let me briefly describe what's in the bill. in terms of ack ser access, peoe getting into health care, this legislation would provide for all necessary medical care without cost sharing or other barriers to treatment. every american -- not 94%, 100% of american citizens would be entitled to care. in terms of choice, the issue is not choice of insurance companies that our republicans are talking about, our republican friends talk about. the question of choice is choice of doctors, choice of hospitals, choice of therapeutic treatments. and under our single-payer legislation, this would provide full choice of physicians and other licensed providers and hospitals. importantly -- and i know there's some confusion here -- a single-payer program is a national health insurance program which utilizes nonprofit private delivery system. it is not a government-run

health care system. it is a government-run insurance program. in other words, people would still be going to the same doctors, still going to the same hospitals and other medical providers. the only difference is that instead of thousands of separately administered programs run at outrageous waste, there would be one health insurance program in america for members of congress, for the poorest people in our country, for all of us. and in that process, we save hundreds of billions of dollars in bureaucratic waste. in terms of benefits, what are you going to get? a single-payer program covers all medically necessary care, including primary care, emergency care, hospital services, mental health servic services, prescriptions -- prescriptions -- eye care, dental care, rehabilitation services, nursing home care as well. in terms of medical decisions, those decisions under a single-payer program are made by the doctors and the patients and

not by bureaucrats in insurance companies. madam president, if we move forward a single-payer program, we can save $350 billion a year due to administrative simplification, both purchasing improved access with greater use of preventive services and early diagnosis of illness. people will be able to get to the doctor when they need rather than wait until they're really sick and end up in a hospital. further and importantly, like other countries with a national health care program, we would be able to negotiate drug prices with the familiarity industry -- with the pharmaceutical industry and end the absurdity of americans being forced to pay two, three, five times more for certain drugs than people around the rest of the world. madam president, every other industrialized country on earth primarily funds health care from broad-based taxes in the same way that we fund the defense

department, social security and other agencies of government. and that is how we would fund a national health care program. not the insane way of millions of different kinds of funding sources which creates the complicated system and enormous waste. let me be specific. what this legislation would do is, number one, eliminate -- underline eliminate -- all payments to private insurance companies so people will not be paying premiums to united healthcare, wellpoint, blue cross, blue shield and others. not one penny. the reason for that is for-private health insurance companies in this country would no longer exist. this legislation would contain all the revenue that flows into current programs as medicare, medicaid and chip, and it would add to that an income tax increase of 2.2% and a payroll tax of 8.7%. this payroll tax would replace

all other employer expenses for employee health care. in other words, madam president, employers in this country, from general motors to a mom and pop store in rural america would no longer be paying one penny toward private insurance revenue. the income tax would take the place of current insurance premiums, co-pays, deductibles and all other out-of-pocket payments made by individuals. for the vast majority of people, a 2.2% income tax is way less than what they now pay for all more in others. that's no longer have to pay for private health care -- private health insurance. and at the end of the day for both the financial perspective and from a health security perspective, we would be better off as individuals and as a nation. what remains in existence, i

should adhere, is the veterans administration. i believe, most of us believe they have a separate set of issues. the v.a. remains as it is. madam president, let me bring my remarks to a close by giving you an example of where i think we should be going as a country in terms of health care. and oddly enough, the process that i think we should be using is what a small country of 23 million people, the country of taiwan, did in 1959. in 1995 taiwan was where we are right now, massive disfaction with a dysfunctional health care system. they did what we didn't tkofplt they said let's put together the best commission we can, let's go all over the world. let's take the best ideas from countries all over the world. as dr. michael chen, taiwan's health insurance bureau, explained in an interview earlier this year the taiwanese ultimately chose to model their system, after a worldwide

search, after our medicare program. that's where they want th*e went. except that they chose to insure the entire population rather than just the elderly. after searching the globe, the taiwanese realized what many americans already tphoefplt a medicare -- already know. a medicare for all, single-payer system is the most effective way to offer quality coverage at a reasonable price. taiwan now offers comprehensive health care to all of their people, and they are spending 6% of their g.d.p. to do that while we spend 16% of our g.d.p. but, unfortunately, the single-payer model was not really ever put on the table here. maybe we should learn something from our friends in taiwan. let me just end by saying this. this country is in the midst of a horrendous health care crisis. we all know that. now we can tinker with the system. we can come up with a 2,000-page

bill which does this, that, and the other thing. but at the end of the day if we are going to do what virtually every other country on earth does -- provide comprehensive universal health care in a cost-effective way, one that does not bankrupt our government or bankrupt individuals, if we're going to do that, you're going to have to take on the private insurance companies and tell them very clearly they are no longer needed. thanks for your service. we don't need you anymore. a medicare-for-all program is the way to go. and i know it's not going to pass today. i know we don't have the votes. i know the insurance company and the drug lobbyists will fight us. but mark my words, madam president, the day will come when this country will do the right thing. and on that day, we will pass a medicare-for-all single-payer system. madam president, let me now move to table senator hutchison's amendment and ask for the yeas

and nays. the presiding officer: is there a sufficient second? there appears to be. the clerk will call the roll. vote: vote:

vote:

vote:

the presiding officer: is there anyone wishing to vote or change their vote? if not, the yeas are 56, the nays are 41. the motion to table is agreed to. the majority leader. mr. reid reid move to reconsided

lay that on the table. madam president, i ask the chair to lay before the senate a message from the house with to h.r. 3326, the department of defense appropriations act. the presiding officer: the chair lays before the senate the message from the house. the clerk: resolved that the house agree to the amendment of the senate to the bill, h.r. 3326, entitled an act make appropriations for the department of defense for the fiscal year ending september 30, 2010, and for other purposes, with an amendment. mr. reid: madam president? the presiding officer: the majority leader. mr. reid: i move to concur on the house amendment and have a cloture motion at the desk. the presiding officer: the clerk will report the motion. the clerk: the senator from nevada, many reid, moves to concur in the house amendment with an amendment. mr. reid: no. i thought there was a cloture motion there.

the clerk: the senator from nevada, mr. reid, moves to concur in the house amendment to the senate amendment. we, the senators senators in accord abc with the rules 22 of the standing rules of the senate, move to bring to a close the debate on the house amendment to. r. 3326, the department of defense appropriations act for fiscal year 2010, signed by 17 senators as follows: inouye, reid of nevada, baucus, leahy, whitehouse, levin, murray, begich, cantwell, pryor, reed of rhode island, kaufman, franken, harkin, webb, kirk, and bennet of colorado. mr. reid: madam president, i move to concur on the house amendment with an amendment which is at the desk. the presiding officer: the clerk will report. the clerk: the senator from nevada, mr. reid, moves to concur in the house amendment to the senate amendment with amendment number 3248. at the end of the amendment, insert the following.

mr. reid: i ask further reading of the amendment be waived. the presiding officer: without objection. mr. reid: i ask for the yeas and nays. the presiding officer: is there a sufficient second? there appears to be. is there a sufficient second? there is. mr. reid: i have an amendment at the desk. the presiding officer: the clerk will report. the clerk: the senator from nevada, mr. reid, proposes an amendment numbered 3252 to amendment numbered 3248. mr. reid: madam president, i have a motion to refer with instructions which are at the desk. the presiding officer: the clerk will report. the clerk: the senator from nevada, mr. reid, moves to refer h.r. 3326 to the committee on appropriations to report back with the following amendment numbered 3249. mr. reid: i ask for the yeas and nays. i ask further reading of the motion be waived and i ask for

the yeas and nays. the presiding officer: without objection. is there a sufficient second? there is. mr. reid: i have an amendment to my instructions which is at the desk. the presiding officer: the clerk will report. the clerk: the senator from nevada, mr. reid, proposes an amendment numbered 3250 to the instructions of amendment 3249 to refer h.r. 3326 to the committee on appropriations. mr. reid: i ask further reading be waived. the presiding officer: without objection. mr. reid: i ask for the yeas and nays on that amendment a. amendment. the presiding officer: is there a sufficient second? there is. mr. reid: madam president, i have a second-degree amendment at the desk. the presiding officer: the clerk will report. the clerk: the senator from nevada, mr. reid, proposes an amendment numbered 3251 to amendment numbered 3250. mr. reid: note the absence of a

quorum. the presiding officer: the clerk will call the roll. mr. durbin: madam president? the presiding officer: the senator from illinois. mr. durbin: ask consent the quorum call be waived. the presiding officer: without objection -- a senator: i object. the presiding officer: objection is heard. quorum call:

mrs. hutchison: madam president? mr. reid: madam president? the presiding officer: the majority leader. mr. reid: are we in a quorum call? the presiding officer: yes, we are. mr. reid: ask consent that be vitiated. the presiding officer: is there

objection? without objection. so ordered. mr. reid: madam president, it's my understanding that the senator from texas wishes to speak for up to five minutes. i ask she be recognized. following that, that senator durbin be recognized. the presiding officer: without objection. mrs. hutchison: madam president? the presiding officer: the senator from texas. mrs. hutchison: madam president, i thank the majority leader for allowing me to speak because i am very concerned about a precedent that has been set on the floor in this last vote. when the senator from vermont withdrew his amendment and started talking, my amendment was the amendment on the floor, my motion to recommit. and i did not have notice, which is the normal procedure here, to be able to talk on my amendment and we had no idea that there would be a motion to table my amendment before i had a chance to close on my amendment. so here is my point.

the amendment that was not tabled -- that was tabled, that was the hutchison-thune amendment, was the amendment that would assure the american people that there would not be four years of tax collections before any kind of program would be put forward under the health care reform act. i thought it was very important that i and senator thune be able to close on our motion because it is, i think, a concept that we have always had in the united states congress that a program starts when it starts and that means if taxes are included, that taxes would start when the program starts. that is not the case in the underlying bill. the underlying health care reform bill has four years of taxes. there will be taxes on insurance companies that will surely raise the premiums of every insurance policy in america. taxes on prescription drug

companies so prescription drug prices will surely go up. taxes on health implement equipment companies, the companies that make health care equipment will also go up. how much? how much are we talking about? we're talking about a hundred billion dollars in taxes that will start in three weeks, that will start in january of 2010. so we're looking at taxes that are going to start in three weeks, next month, that will accumulate up to $73 billion before any bill is implemented that will give anyone a choice of a new health care option. so, madam president, that is the amendment that was tabled just ten minutes ago, and i want to make sure that everyone knows

that this -- i never had a chance to close on the amendment. senator thune didn't have a chance to close on the amendment because it was a motion made that could not be objected to. that's not the way that things have operated here in the past, and i think that it is time that we bring back the traditions of the senate, where we have time tables that we agree to, everyone has their say and then we go forward. and so i am very concerned about that process. i hope it is not setting a precedent because i think we can resurrect health care reform if we have bipartisan health care effort, if we have an effort that will bring down the cost, that will increase the employment pools so that an employer will be able to afford to offer employees health care coverage, bring down the the cost of health care with medical malpractice reform that would save $100 billion in the system. we can do things without a government takeover of health

care. but the bill that is before us has a half a trillion dollars in medicare cuts -- medicare cuts -- a half a trillion dollars, and a half a trillion dollars in new taxes, taxes on businesses that offer not enough coverage, businesses that offer too much coverage, a 40% excise tax on policies that give what's called cadillac coverage, the high coverage levels. so if you have a really good insurance policy, you have a 40% premium on that on top of the premium that you pay. and if you have too little coverage, you also get taxed. so, you're whipsawed in this bill. i think the small business people of this country know what this bill is about because that's the comment that we're getting. that's the people who are calling into our offices. it's the people that i'm seeing

on the airplanes as i go back and forth to try to make sure that we are covering the bases on this bill and trying to let the american people know what is in it. so, madam president, i'm concerned about the precedent that was set. but more than that, i am concerned that the american people must know that if this bill passes as it is on the floor today, the taxes will take effect in three weeks, that insurance premiums will surely go up. prescription drugs will surely go up. medical equipment will surely go up, and there will be no program for people to choose to take for four years. it's like buying a house and having the mortgage company hand you the keys and say "come back in four years, and we'll let you unlock the door." mr. president, i don't think that's transparency, and it is

certainly not health care reform. and i hope there is still a chance that we can bring this body to a bipartisan effort that will allow lower premiums, more health care opgs for -- options for the people this have country, but most importantly, that would keep the quality of health care, the choices that we have in health care that americans have come to expect. and not start going on the road to a single-payer system, because in the end that is what the bill before us will lead to. it will be a single-payer system. it will take the choices out. it will take the quality out. it will add taxes and burdens on our small businesses at a time when they need to be able to hire people to get our economy and to get that joblessness rate down, we need to employ people. we need to encourage our

employers to employ people. they cannot do it if we put more taxes and burdens on them, which is what the bill before us does. mr. president, i thank the majority leader for allowing me to speak since i did not have a chance to speak before my amendment was tabled. i hope the american people are listening, because we have a chance to do this right, but the bill on the floor today is not that bill. thank you, mr. president, and i yield the floor. mr. durbin: mr. president? the presiding officer: the senator from illinois is recognized. mr. durbin: mr. president, i thank the senator from texas, and i'm glad she had her opportunity. we disagree on this but i'm glad she had her opportunity to speak. i hear from different people. obviously we must ride on different planes because the people that i speak to are anxious to see some change in this health care system. they knee 14,000 americans -- they know 14,000 americans lose their health insurance every single day. and they know most people can't

afford health insurance because of the increasing costs. i say to the senator from texas, you're my friend, we've worked together on many things in the past. we disagree on this issue. i'm coming forward with a holiday proposal. recent there was a book published about world war 1. it's about trench warfare that went on and on with horrendous casualities and lives being lost. then there came a moment, a christmas moment when they decided to call a truce because of christmas and play a soccer game. and the allied troops came out and for a brief moment stopped the war, played the soccer game and then went back to the trenches and the next day started shooting again. i'm looking for a holiday truce here for our troops because what we have before us right now is the department of defense appropriations bill. and although senator hutchison and i clearly disagree, and many members here on both sides clearly disagree when it comes to health care, there is no disagreement when it comes to our troops. every one of us supports our

troops. every one of us wants to make sure they have what they need, the resources they need to perform their mission successfully and come home safely. and this bill that is before us, this department of defense appropriation conference report, is an attempt for us to do something to help these troops in time of war. and i would hope that i could appeal to my colleagues on the other side of the aisle that for one brief shining moment in the spirit of the holiday we set aside our political differences for the sake of our men and women in uniform. the point i'm getting to is that if we go through the ordinary tortured procedure and wait, it's going to take us days to complete this bill for our troops. and i would hope that we could show good faith on both sides of the aisle and overcome that. i would hope that we could enter into a consent agreement among republicans and democrats because i just know as i stand here that the republicans feel as the democrats do, that we should provide the funding for

our overseas operations of our men and women in uniform. in this bill, $101 billion is included for operations and maintenance for ongoing military operations in iraq and afghanistan and to support the preparations to continue withdrawal from iraq. in this bill, $23.6 billion for equipment. we want to make sure that our men and women in uniform have the equipment they need to make certain that they are safe and have what they need to come home safely. there's also a pay raise in here, 3.4% pay raise. does anyone dispute the need our military has to be recognized for what they do in this country and be given a pay raise? when it comes to training, $154 billion for the defense operation and maintenance account to increase the readiness and training of our troops. in the field of military health care, $29 billion for the defense health program to provide quality care for service members and their families. it includes $120 million for traumatic brain injury and

psychological health research. these are issues we have all come together on. we're not arguing about these issues, and i don't think we should at this moment. $472 million for family advocacy programs and full funding for family support and yellow ribbon to provide support to military families, including child care, job training for spouses, counseling and outreach. there's one other section of the bill that i will yield to my friend from alaska for a when. there is one other section that relates to the unemployment crisis facing this country. it is only a modest extension of unemployment benefits but the last time this was on the floor i believe it passed 97-o. i don't believe there is any controversy associated with the fact that we want to extend unemployment insurance benefits through february 28 of next year. i would just say it's difficult for me to envision a situation where we would actually leave here to go home to our families for the holidays and not take

care of the unemployed? there is also a provision for their health insurance under cobra and for food stamps which we know so many unemployed families rely on. it seems to me if there is one thing in the pheufdz all this political turmoil we can agree is let's stand behind our troops and make sure the people we employed have a happy holiday season. why do we want to have a tortured process to reach a yes on this. let's do this part. we can return then to the health care bill and the debate. but let's get this done and do it without all of the necessary motions and time that may be spent. and i yield for a question from the senator from alaska. the presiding officer: the senator from alaska is recognized. mr. begich: thank you, mr. president. i appreciate the senator from illinois bringing up what i consider one of the most important pieces of legislation. we have thousands of military families and individuals. i'm now this process, so one of

the questions i had for the senator -- aeupbd know he can enlighten me but i hope the whole public. this is probably one of the most important departments that we're at at this time, in two wars. i'd like you to give me an explanation in the past, defense bills seems to be one of those in which we all come together. it seems every time we deal with these issues we are unified. help me to understand why this might be something that might be controversial but should be so simple for to us do. mr. durbin: i think it is the moment. if we were in a different political environment, i think the republican senators and democratic senators would agree this should go through and go quickly. but we have been caught up in weeks now of debate and controversy. and this bill has been tossed into that environment. and that i think is the explanation because i don't think there's a single provision

that i read here that the republican senators don't support as the democratic senators support. that's why i made my suggestion. mr. begich: mr. president, if i could ask one more question. that last statement you made, as a member of the armed services committee, i haven't heard complaints about this bill from anyone from the other side. i'm asking, i guess, from the leadership position have we heard any complaints on this? is it just the moment in time? mr. durbin: it does include some provisions relative to the unemployed. there were other things that could have been included by the house but we reached out through the republican side and said are any of these problematic. by and large they said here are certain things you should not include and we did not. we did our best to make sure we brought a noncontroversial bill for consideration. ms. stabenow: i would ask the senator to yield. mr. durbin: thaoep yield to the senator from michigan -- happy to yield to the senator from mitch.

ms. stabenow: thank you very much. i twaoupbt clarify this -- i want you to clarify this again. we could do this again today, if there was willingness to do this. secondly, we have a pay raise for our troops that is coming right now, right before christmas, the holidays: help for families, help for those who have lost their jobs and are trying to figure out how they keep their health care going and help for people trying to put food on the table of the holidays. is that correct? i would ask the senator to expand. and the fact that we could -- as i understand it, we could actually get this done today and give people some peace of mind going into the holidays? mr. durbin: yes, we could enter into a consent now and pass this conference report without controversy. i'll bet you it would get a unanimous news vote. everybody here wants to make sure we take care of our troops. we received a unanimous vote, if memory serves me, the last time we extended unemployment

benefits. i think most members want to stand up and help those who are unemployed through this difficult time. if there ever was a bill that could bring us together in those two area: helping the troops and helping the unemployed, this is the bill. ms. stabenow: i would ask one other question to the senator from illinois. if in fact you are finding the same thing i am right now -- certainly we have the highest unemployment rate in michigan, but we're hearing from people whose unemployment is about to expire. they're trying to figure out how they're going to make it through the next few months. there are particular concerns that if we don't extend this by the end of the year that in fact many will have to sign up with new bureaucracy and so on to be able to continue their benefits. i'm wondering if the senator, if you have heard the same kinds of concerns and sense of urgency that people have about being able to keep a roof over their head and keep food on the table

and keep their health care going, and the same sense of urgency i know we're feeling from people in michigan. mr. durbin: we are, i guess, happy to read the latest unemployment statistics showing that the number of people declared unemployed each month is going down. we won't feel good about it until it's turned around and we're creating jobs again, which i hope is soon. in the meantime, we have about six unemployed people for every job that's available. and these people are in a market that is terrible. and they're trying their best. some have gone back to school, some are getting training courses, some are just trying to keep things together with their family and not lose their home because of employment. i'm sure you met with the unemployed in michigan. some are little by little exhausting the savings that they have. most of them do not have health insurance. even with this cobra, many people find with the cobra provision in here which gives

people a chance to buy insurance at a discount it is still too expensive. there they are desperately looking for a job. we certainly don't want to put them in a situation where there's a question mark as to whether after december 31 the unemployment check will be there next month. and i think it's that peace of mind which we owe these folks who are caught up in the bad circumstances of our economy. ms. stabenow: if i might just conclude, mr. president. i we could get this done today. we could create a peace of mind for those going into the holidays and into christmas and the end of the year. we could do that in the nieks hours is that correct -- is that correct? mr. durbin: earlier we were embroiled in the reading of an amendment that would have consumed the entire day and forced us into another day's time an run the risk of not providing money for the troops when the continuing resolution

-- the funding resolution ran out. well, the senator from vermont withdrew his amendment and now we moved to this bill. but there is nothing stopping us, a consent could be entered into by both sides of the aisle that could move this through quickly and say to our troops, we're with you. ms. stabenow: thank you. mr. durbin: the senator from rhode island. mr. whitehouse: would the senator from illinois yield for a question? mr. durbin: i will. mr. whitehouse: i'm interested in the parliamentary situation that took place earlier whereby one of our members was actually obliged to withdraw an amendment that was going to be voted on by all of us because of an insistence on part of the other side, that 800 pages, be read by our poor clerk, before that vote should take place. and i -- i have also heard the other side say that we want to

get going and we want to move toward votes. and i would be interested in the distinguished majority whip's reflection on the extent to which a procedural objection to force the clerk to read 800 pages of an amendment and deny one of our colleagues his vote fairly represents a desire to move forward and get through our votes. mr. durbin: i'd say in response to the senator from rhode island, that we have heard repeatedly that people want debate, amendments, and vote. and, yet, what happened on the floor today when the senator from oklahoma, senator coburn, refused to give consent to suspend the reading of the amendment was that the clerk -- clerks, i should say, were forced to start reading. and as good as they are at reading, the fact is it was going to take up to 10 hours to read this 080-page amendment -- 800-page amendment. that meant during that time nothing could happen, no debates, no amendments, other

than the clerk's voice. fortunately for us the senator from vermont stepped up and said, i withdraw the amendment. if there was a true interest in debates on amendments in health care, it really is inconsistent to say that we're going to take a whole day out of the affair and read the amendment. as i said to the senator from oklahoma, i can't believe there's a person in america who sat glued to the c-span television set listening to the tv set so they could understand it. it is a complicated amendment, page by page, but in general understandable. it was senator sanders looking for a single-payer health care system. i would say that the strategy on the floor today belies any request that we have more debates and more amendments. before the senator from rhode island continues, i think this has been cleared on both sides, but i'd like to ask unanimous consent that the time until 6:15 p.m. be with equal -- be

equally divided between the two sides with senators permitted to speak up to 15 minutes each. the presiding officer: without objection, so ordered. mr. whitehouse: would the senator from illinois yield for another question. i was elected just about three years ago and i came in with a new majority. so i did not have the chance to serve in this body when there was a republican president and a republican majority. and i wonder if the senator who was here at this time would reflect on how the other side viewed defense appropriations for our troops during the iraq war when they were in the majority. were they desirous of delay and obstruction and debate an procedural -- and procedural maneuver on defense appropriations at that time or is this a new strategy of their?

mr. durbin: i would say to my colleague from rhode island, exactly the opposite was true. they wanted to move quickly to pass any appropriation bill to make certain that there was no question in the mind of our men and women in uniform that we are standing with them. and we did. even though who voted against the invasion of iraq, stopped the proceedings from funding the troops regardless of what our votes might be. and so i think it would be consistent now for our colleagues on the other side of the aisle to join us in a bipartisan fashion to say whatever differences our other issues, like health care, let our troops know this holiday season we stand behind them, republicans and democrats, and want to do it in an efficient and effective way. and, mr. president, since this unanimous consent request has been granted, i am going to yield the floor and any of my colleagues who wish to speak, it's going to be equally divided time for the next two hours, and so at this point i will yield the floor.

mr. durbin: i suggest the time be taken equally from both sides. the presiding officer: is there objection? without objection, so ordered. the clerk will call the roll. quorum call:

quorum call:

a senator: mr. president? the presiding officer: the senator from florida is

recognized. mr. lemieux: i ask that the quorum call be dispensed with and an opportunity to speak. the presiding officer: without objection, it's so ordered. mr. lemieux: mr. president, while we've been here discussing health care, the clock has been ticking on our national debt. just in the last -- in the first two months of this fiscal year, we've accumulated $296 billion in debt. we took in revenues of $268 billion and we spent $565 billion. we spent double what we took in just in the first two months of the fiscal year. mr. president, i know you're new to this chamber, as am i. i've only been here about 90 days, but i've been here long enough to know that this system is broken, it doesn't work. this body nor the body across the capitol have an ability to make ends meet. we continue to spend money we do not have. we spend the money of our children and our grandchildren.

right now we have a $12 trillion debt. a $12 trillion debt. it took u us 167 years in this country just to amass a $1 trillion debt in 1982. and now we're at $12 trillion. every family in this country is now responsible for $100,000 of debt. where are we getting this money this we're borrowing it from countries like china, and it's hurting our standing in the world. central banks that hold american currency are shedding those dollars because this no longer feel that our country's a good investment. mr. president, i worry about our children and our grandchildren. i have three sons, as you know, max, taylor and chase. they're 6, 4 and 2. we have a baby on the way in march. and i am very worried that my children will not be able to experience the american dream like you and i have. to be able to be in the united

states senate, to be able to achieve all of our goals, whether in public service or in private, i don't believe that america's going to be the same place for them, that it's going to hold the same opportunities, because i believe this debt is going to strangle us. and if ha this body and the body across the capitol doesn't figure out that we need to start making ends meet and stop spending the future generation's dollars, this country will not be the leader of the world t. wilworld.it will not have the pe that we all enjoy. so i rise today, mr. president, to speak about senate joint resolution 22 which i filed yesterday, a constitutional amendment that requires the united states congress to balance its budget and also gives to the president of the united states a line-item veto so that he, like most of the governors in this country, can strike out inappropriate budget items, these earmarks that you hear about. senator mccain spoke this

weekend about $2.5 trillion to the university of nebraska to study operations and medical procedures in space. we can't afford that program under any circumstance and we certainly can't afford programs like that when we are $12 trillion in debt. you know, these dollar numbers are so booed they're hard to comprehend. what does a trillion dollars mean? what does a billion dollars mean. in washington, we throw these amounts around and we don't even comprehend them. and i know the american people at home, it's hard to get your mind around how much money this is. and i've said this on the floor before and i'm going to keep saying it so people every dollar we spend is a choice. a million dollars of dollars laid edge to edge on the ground would cover two football fields. a billion dollars laid edge to edge on the ground would cover the city of key west. west, 3.4.

if you stacked up up to the skies, it would be 600 miles of $1 bills. every number is a choice, and these numbers are out of control. just this past saturday, mr. president, we voted on a spending bill, a spending bill that had a 12% increase and more than a $40 million -- $40 billion more than last year. i want to give the american people a sense of what you could do with this kind of money. what good you could tkofplt or better yet, you could give it back to the american people and they could decide what good they could do with those dollars with their families. $100 billion, we could give every floridian a $5,000 tax cut. $200 billion we could pay the salary of every teacher in america for a year. $300 billion we could pay first-year tuition at a

university of their choice for every kid who is in k-12 in this country. every child. with $400 billion, we could build high-speed rail around this country for 10,000 miles. we could connect key west to anchorage and back. every dollar, mr. president, is a choice, and we are spending money out of control. so like those who have come before me, i'm going to sound the alarm. i'm going to sound the alarm because we still haven't done anything about this problem. now there are good measures out there. senator gregg from new hampshire has a measure along with senator conrad to put together a commission. i support that. senator sessions has a measure to bring caps back because up until about 2002, we actually were making some headway against the budget. then those caps expired and spending went out of control. i support those efforts. i support any effort to bring spending in control because this

body doesn't have any leadership on spending. we just look at what we spend. we don't look at the revenues that are coming in the door. mr. president, you know i served as a chief of staff to a governor in florida when the budget started to go bad in 2007, i was on the phone monthly, weekly, with the person who determined our receipts because i knew in florida we could only spend as much money as we had. this institution doesn't work that way. no one even checks to see what kind of money where bringing in. we just spend. i want to talk to you, mr. president, and to the american people about an article that is in the "wall street journal" today. i want to be clear, this is not a democrat problem or republican problem. this is a problem of this institution. the article is entitled "the audacity of debt." i want to quote one paragraph and i ask unanimous consent that this be placed in the record. the presiding officer: without objection, so ordered. mr. lemieux: "democrats ridiculed mr. bush as the most

fiscally irresponsible president in history, but then they saw him and raced. they took a $800 billion deficit and made it $1.2 trillion in 2009 and perhaps that high again in 2010. in ten months they have approved more than $1 trillion in spending that has saved union public jobs but done little to assist private job creation. still to come is this multitrillion-dollar health care bill and another $100 billion to $200 billion in jobs bills." we can't afford the programs we have let alone the programs we want. so i filed this joint resolution to have a balanced budget, and i filed this joint resolution to give the president the line-item veto like governors do. and i know i'm tilting at windmills, mr. president, because i know there are few people in this chamber or the chamber down the hall that have the courage to do this because they're part of this process. they go along and get along. but i'm fresh enough,

mr. president, as you are to still remember how things work in the real world. we've pwot to change things -- we've got to change things because our children are not going to have this great country. i'm so afraid, mr. president, that one of my kids is going to come to me when they're 18 or 22 and say "dad, i'm going to go to another country to make my living in my life. i'm going to go to ireland or chile or india because i've got a better chance there to succeed. i can't pay 60% taxes. i can't saoupl what will be a $20 billion or $30 billion debt." we're not talking about the entitlements we haven't paid for. we're not talking about the money we've raided from medicare or social security in order to pay for current expenses. some people say those obligations are more than $60 trillion, numbers we can't even comprehend. i filed this resolution. i'm going to send a letter to every governor in this country

asking them to adopt it in advance of the congress taking it up. the constitutional amendment, as you know, mr. president, requires two-thirds of both chambers and three-quarters of the states. they can act first. they can send letters and resolutions from their legislators to this legislative body and say get your act under control. because it affects them too, this new health care bill that we have is going to send an unfunded mandate to the state and increasing medicaid from 100% of poverty to 133%. they're going to have to pay that bill. it's going to cost florida in ten years almost $1 billion. right now in florida the number-one expenditure in our budget is medicaid. and because we balance our budget, that means we take money away from teachers and education. that means we take money away from law enforcement. it's out of control. it is out of control.

so i'm here to say that the siren is sounding. the ship is going to hit the iceberg. and we can't make just incremental change because then we'll just hit the side of the iceberg. we've got to make substantial change. and the people in this body have to have the courage to do it. we can't just go along and get along like we've been before. we cannot be tone-deaf to this. the american people, mr. president, are on to us. they're on to us. they understand that we're spending money that we don't have. i will not stand by and let this great country fall into decline without at least arguing and pushing as strenuously as i can for a solution. and i'm willing to work with men and women of goodwill on both sides of the aisle to solve this problem. i'm new here. i might not have all the answers. i probably don't. but i will surely work hard and tphoeu that this is one solution -- and i know this is one solution. if every state in the country can have a balanced budget

amendment and 43 states can have a line-item veto, why can't this body? mr. president, i filed this resolution. i look forward to talking about it more. aeupbd hope that this body will take -- and i hope this body will take it seriously. i see my friend from massachusetts is here as well. he also is new to this body, although he spent many years working here. we've got to do things differently. we throw around billions and trillions in this chamber like it's just nickels and dimes in our pockets. and it's not. every dollar is a choice, and it's a choice to make. and if we don't make the right choice. it will be a choice that our children and our grandchildren will suffer under. thank you, mr. president. i yield the floor. a senator: mr. president? the presiding officer: the senator from massachusetts is recognized. mr. kirk: thank you, mr. president. the need for comprehensive national health insurance and

concomitant changes in the organization and delivery of health care in the united states of america is the single-most important issue of health policy today. those are not my words. those are the words of senator edward m. kennedy. the today of which he spoke was december 16, 1969, exactly 40 years ago today. it was his first major speech on health care reform, and i was privileged to be a young member of his staff. he delivered that speech to a group of physicians at boston university medical center. senator kennedy went on to say -- and i quote -- "if we are to reach our goal of bringing

adequate health care to all our citizens, we must have full cooperation between congress, the administration, and the health profession. we already possess the knowledge and the technology to achieve our goal. all we need is the will. the challenge is enormous, but i am confident that we are all equal to the task." close quote. the world has progressed in many ways since he spoke those words four decades ago. but our health care system has not. in 1969, the united states spent $18 billion on health care. today we spend over $2 trillion a year. senator kennedy pointed out in 1969 that the nation faced a shortage of primary care doctors. the reimbursement rates for

physicians treating medicare and kphaeupd patients were too low. it was a need to support greater innovation and delivering care and neighborhood health centers were underfunded. he said we needed to develop an effective means of providing quality, affordable care to all americans, regardless of their standing in life. does all this sound familiar, mr. president? yes. but that was then and this is now. mr. president, in recent weeks senators on both sides of the aisle have come to this floor to debate the merits of the patient protection and affordable care act. we have had our differences of opinion, to be sure. but on one issue there is no dispute. when it comes to our health care system, there is no such thing as a status quo.

we will move forward or we will continue to fall behind. and here is what we will face if we do not pass this reform. premiums will skyrocket and could consume as much as 45% of a median family's income by 2016. bankruptcies will increase due to families not being able to afford their medical costs. more americans will be uninsured. small and large businesses will suffer financially due to the health cost increases. health care could constitute as much as 28% of our nation's g.d.p. by 2030. 15% of the federal budget could be dedicated to medicare and medicaid by 2040. ted kennedy had a keen sense of history. he knew if germany adopted the idea of health care insurance in the 18 80's, that britain,

france and a number of other european nations embraced the concept after the first world war. canada had a public-funded system since the 1950's. he would ask, as he did in 1969 and again in 2009, if all these nations understood long ago that their economic health is ultimately tied to the health of their people, why does the united states stand alone as the only major industrial nation in the world that fails to guarantee health care for all its citizens? it's not that we have never sought this goal in the past. presidents, republicans and democrats over many decades proposed national health insurance in america *fplt presidents theodore roosevelt, franklin roefrlt, harry -- roosevelt, harry truman, bill clinton and richard nixon made health care reform a part of their agenda. now we stand on the threshold of

history. never has this country been so close to bringing affordable quality health care to millions of american families. today under president obama's leadership, the goal is within our reach, and failure is not an option. all interested parties have been brought to the table. physicians, hospitals, insurance companies, small businesses, pharmaceutical companies, and many others have had an opportunity to present their suggestions and offer their input. dozens of hearings were held on all topics related to this issue. the house of representatives has acted. the senate "help" committee, through the diligence and dedication of senators kennedy, senator dodd, senator harkin, and the finance committee under the leadership of senator baucus held lengthy executive sessions and discussed all areas of reform and delivered and

developed their respective bills. now due to the hard work and tireless patience of the majority leader, we have one merged bill before us. a single piece of legislation which will improve the lives of millions of americans in the following ways: it expands coverage to an additional 31 million americans, bringing health insurance to almost 94% of our american citizens. it saves money by rewarding the quality and value of care, not the quantity and volume of care. it controls the costs of skyrocketing premiums and limits out-of-pocket expenses. it reduces the federal deficit by an estimated $130 billion in the first ten years and an estimated $650 billion in the second ten years. it stimulates competition in the health insurance marketplace through establishment of