21% of the people who are insured could not get health care because they could not afford it. that's somebody that is very well respected on the majority d it's something we've been saying. and they're saying the same thing. the fact is we're, what we're going to do is put 15 million people into medicaid that we know has worse outcomes, we know is an unfunded mandate on the states, and we know 40% of the doctors refuse to see this. so you're not going to get to choose the doctor that you want. you are going to have state mandates in terms of what is available to you and what is not. so we violated two of the key premises with which to reform health care. i'd also like to quote what i

thought is a brilliant letter by a dr. robert geist from st. paul, minnesota, written as a letter to the editor in the "wall street journal" today. and the title of his letter to the editor is "the first cost comptroller will be your own doctor." it's something i've been talking about since we started this. the last thing we want to do in health care in america is to make it where the doctor is not 100% advocate for the patient's best interest. and he quotes very directly the transfer. he says -- he said, a previous article written did not emphasize a potential stealth cost control aspect of the bill. it will transfer the gatekeeper role to the doctors at the bedside arcs role currently held by payers, the government, and h.m.o.'s and insurance agencies, including medicare and medicaid.

the transfer will be by capitation of fee payments, making clinics responsible for the cost of care of insured lives for one year. the illusion of many pundits and policy-makers is that many provider -- mini provider gatekeepers can control costs after powerful gatekeepers, i.e., medicare, medicaid and large insurance companies, have failed for decades. the problem for payments is the dilemma of all managed care gatekeepers. cost, quality being access -- pick any two. it is not pleasant to think that one's gatekeeper doctor will have to decide whether to order surgery for your painful, worn-out hip or to increase your dose of anti-inflammatories because they're worried about costs. that's the key point. we're going to now separate physicians in this country from doing what's best for the patient to meet the demands of

the government. i'll be happy to yield. mr. ensign: as a practicing physician, isn't this what you saw in your practice with h.m.o.'s? mr. coburn: that's why i'm not a member of any h.m.o.'s. mr. ensign: we kind of have an insurance-centered system today to a large degree, and now we're going to make that worse. instead of going more toward a patient-centered, we're going to go from an insurance-centered to a government-centered, to where these government bureaucrats now start being in control of the eventually what kind of care you're going to get, what's paid for and all of that. and we need to put the doctor and the patient back at the center of our health care system. mr. coburn: let me finish this for a minute if i might. here's the summarizing paragraph. the economic reality is that no rationing of care supply will ever control costs when the problem is demand inflation driven by popular insurance tax

subsidies too sacred to repeal. consider that when federal fiscal necessity overwhelmed the empty slogans -- our empty slogans, scores of new bureaucracies created in this bill would be able to implement draconian rationing in collusion with subservient insurance and provider corporations. the high costs as well as the rationing powers included in the more than 2,000 pages of the obama-senate legislation are very real, which is a point i've been making all along. and i'm going to spend 30 minutes tomorrow talking about the rationing aspects of what we're about to do as we pass this bill. mr. burr: if i could comment to my good friend who started on a quest with me several years ago to try to put together a health care reform bill. it was the first introduced in this congress, may of this year, comprehensive health care

reform. not that it's better than anybody else's, but i can honestly say today it was true reform. and i think that's what dr. coburn's trying to say. in this bill, it lacks reform. what do i mean by that? their reform is to set up an advisory panel that if we exceed the costs that we've designated for health care, that they're going to cut the scope of coverage or the reimbursement. so either the array of coverage for a senior or for an american is ski nied down or we cut the reimbursement to the doctor or the hospital and they call that reform. what we found out, if you look at successful companies across this country who have held down their health care costs through doing real reform, weighing for prevention and wellness to work, changing the lifestyles of the employees that they have, we saw companies that for four years

had a .5% increase in their health care. where is any of that in this bill? and out of 2,700-plus pages, there is no attempt to do that. there is no attempt to try to effect the lifestyles through supporting chronic disease management, prevention and wellness. but we set up a lost independent advisory boards. as a matter of fact, they were so scared that in the manager's amendment, it's no longer called the medicare independent advisory board t.'s called the independent advisory board so the word medicare was dropped out not to signify that they're going to cut medicare. but that's exactly what c.b.o. and c.m.s. have said. these will kick in, and the question is: are they sustainable or will congress legislatively override their authority to cut the spending? mr. ensign: if my friend will yield, there is one part, actually one of the best parts in this bill. but there's so much other bad

parts of this bill -- and you've mentioned we've talked about a lot of them. the one place that they actually have improved our health care system would be the part that allows people to have larger discounts for healthier behaviors. safeway was the model this have where today they can discount up to 20% of their health care premiums for people who engage in healthier behaviors, for not smoking, for being the proper body weight compared to their height; doing things like that. even if they're a nonstphoerbg they get a lower premium. if they quit smoking, and safeway paid for the smoking cessation products and things like that. to be fair, that is actually in the bill. senator kaerp and i got that, in the finance committee we were able to get that amendment drafted. the problem is that's a tiny part of this bill. that should be a major focus of the bill. we should be able to buy

insurance across state lines. small business health plans where small businesses could join together and take advantage of purchasing power. we all on this side, almost everybody on this side of the aisle agrees with medical liability reform. the congressional budget office said that would save $100 billion. the bottom line is what we've been focusing on -- and i appreciate the efforts the two of you made in your bill last year of trying to address the number-one problem we have in health care in the united states, is cost. this bill doesn't address cost. as a matter of fact, you said it in your opening remarks, cost actually, according to president obama, c.m.s., go up, total health care spending by $234 billion over if nothing was done. if nothing's done, we actually save money on total health care spending. but with this bill, it actually goes up by $234 billion. mr. coburn: we also know from the congressional budget office is that between 9 million and 10

million people who today have insurance through their employer will actually lose it. they're going to lose their insurance. so -- and that may be good or bad for them. but the incentives, if you look at the incentives, the subsidy for people who don't get insurance through their employer, if you make $42,000 a year today with your health insurance through your employer, you get a benefit of about $5,749 from the tax system. but under this bill, you'll be eligible for $12,500 worth of subsidy. so what do you think an employer's going to do? they're going to look at their employees and they're going to say i have to pay this penalty if i don't offer this, but it's a significantly smaller amount than what i'm paying today. so, therefore, i'm going to make a decision to no longer offer health insurance, give my employees a small raise because

the government is going to come in with $12,500 worth of subsidy to put them in a private, -- quote -- "private plan" inside the parameters in the exchange. how many people do you think are going to shift? what we're going to get is we're going to get adverse selection. and so the individual -- let's say i'm working and i'm making $42,000 a year. my employer decides to do that. let's say i'm 35 years old, and i know available to me is $12,500 even though my earnings may go up, i'm still two and a half times better off. but i also know that i would have to pay $3,000 or $4,000 of my own money to get that benefit. i just won't cover myself because i know i can cover my little incidentals, and if i get sick, they have to cover me in the exchange. so we're going to see adverse selection in the insurance market. people who are between 40 and

64, who are sick are going to pay far more for their health insurance. and people who are sick that are younger than 40 are going to pay far more for their health insurance. and everybody that's healthy under 40 is going to say this is an economic bonanza for me. i'm not going to buy insurance. mr. ensign: i see our friend from south carolina has joined us. you've spoken eloquently, i think, about some of the sweetheart deals that have been made in this plan to -- quote -- "buy votes." could the senator from south carolina address those? mr. graham: thank you very much. i don't know if you could call this a sweetheart deal more than it's just repugnant. the twain of 2008 was -- the campaign of 2008 was about change we could believe in. and i really do believe that one of the reasons president obama won is because he convinced young people in this country that if i get to be president this, country's going to change

for the better. we're going to do things differently. and that resonated with people because, quite frankly, when we were in charge as republicans, we let people down. you know, we let things get out of control on our watch. some of our people wound up going to jail. the iraq war was not popular. so you've got this new young, exciting, very articulate figure come along and promise a new way of doing business. that's what hurt so much about this bill. the special deals you just mentioned reminds us all of why congress is in such low standing. the 60th vote, how did they get it? did they negotiate the 60th vote on c-span in a transparent manner promised in the campaign, that we would have negotiations on c-span so you the american people could watch what was being given and what was being taken and there would be no more backroom deals? here's what happened.

they took one senator who is the key guy, and they put him in a room, and we had no access to that room, and no democrat really did either. and after it was all said and done, here's what resulted from those negotiations that were not on c-span. nebraska is going to be the only state in the union, ladies and gentlemen, that new medicaid enrollees will be covered by the federal government. every other state in the union, when you sign up a new person on medicaid, because you're expanding the number of people eligible for medicaid, your state is going to have to make a matching contribution. in my state of south carolina w-rbgs 12% unemployment, there will be a half a million more people eligible for medicaid thupbd bill than exists -- under this bill than exists today. it will cost south carolina $1 million. but if you live in nebraska, it doesn't cost you a damn dime because that's what it took to get a vote.

if that's change we can believe in, count me out. and if that's okay with the american people, i can tell you our best days are behind us. insurance companies in nebraska got a deal that no other insurance company in the nation got. physicians-owned hospitals in nebraska got a deal nobody else got. louisiana got millions of dollars to help with their medicaid problems that nobody else got. if you want your country to be run in a more businesslike fashion, then you need to speak up. you've got a chance between now and sometime in january, when this goes back to the house, to let your voice be heard. so to my good friend from nevada, the special deals in this bill are not special. they are the same old crap that we've been putting wup for decades -- putting up with for decades up here and people thought was going to come to an end. and it's going to hurt your

children's ability to have half of what you've got because they can't make it because you're about to pass on a bill to them they can't pay. so what i hope will happen to my good friend, the senator from nevada, that people will take their government back. and if you think this deal from nebraska is unacceptable, speak up and speak out and let the house members know that you want it changed. mr. burr: i thank our colleague from south carolina. i know we're about to run out of time, but i wanted to go back to the chief actuary at medicare, because i think the way they analyzed the bill is absolutely essential for the american people to understand what's in it. the chief actuary, the president's actuary said the reid bill funds $930 billion in ne