went up dramatically. i was in a position where it was absorbing about 80% of all of the revenue growth that we had in the state of tennessee, clearly, not a viable proposition, and i was to be honest with you neither cms nor the federal courts wanted to give us help at all in any sort of a more nuanced way, and we ended up just having to dramatically change benefits and have people lose their coverage, but that's what happens when you don't -- i think engage in the need to do things with health care. that's my fear about what's going to happen with medicare in the long run. if you don't get in and change the underlying reasons why the cost goes up, at some point it crashes and who gets hurt is not the congress, but all the elderly people who need the

care. we need to engage with these problems. >> okay. thank you. let's take some audience questions. first is this. how severe are the projected risks for state budgets given health reform. you touched on that a little bit with medicaid. >> it's substantial. it's a huge change for medicaid for the states. in tennessee, we estimated that in tecond >> in tennessee, we estimated that in the second five years period was when it's 2014-2019. n new expenditures for the state, but that's at a time where we're just getting back to the levels we were in 2007-2008 of our budget, so it really is a problem. it's a problem for us. it's a pretty significant issue, and it's a real, i think, breaking of a contract or breaking of on understanding that worked for 45 years between the states and federal

government. >> one question, because we have to wrap it up. it's a good one. it has to do with state's implementation of health reform. there's a lot of uncertainty with the law, congressional uncertainty, frawl court, maybe supreme court. do you think it's the states to put it into law or be slow in moving forward? >> jim douglas, the republican governor of vermont, and i did a seminar if the new governor's boot camp that we have every time there's a new crop of governors, and both he and i feel no matter what your feeling is on reform, you're crazy not to go down the path of beginning to plan for the exchanges because it doesn't hurt you if reform is terminated or changed dramatically, and if you haven't started now, you want be able to -- you won't be able to implement

them and there's vast control of health care decisions made in your state to the federal government. unfortunatelily, that's not happening because it's a political litmus test and they fight it to refuse the money. any state that doesn't plan for this ire respect of their opinion is crazy. >> thank you, governor for being with us this morning. [applause] >> it was my pleasure to present this excellent panel coming up. now we have a mic. as the economics of health care become an issue around the globe, we're faced with the need to find a more effective health care approach for the next generation. innovative health care technology, information, consumer ingaugement in health

care and early detection of chronic diseases are all essential in coordinating care. each of us is drengtly impacted by health care decisions we make every day for our employees, for ourselves. this subject matters a great deal to vision care. we have employees all over the world, and the largest non-for-profit care in the united states, we have 5600 members we cover across the country. eye care is an example of a nontraditional way to provide health care for people who are not meeting with their primary physician. eye doctors and opt molingses can see early signs of chronic diseases through eye examines and take their patient forward to other care. with a small part of the health care system with a larger part of the system, significant savings are realized.

we know through a third party study we conducted with our members that over 4.5 -- $4.5 billion were saved in health care avoidance with employers who had our health care plan. they benefited with the cost savings making it more affordable for them to provide health care benefits. when you extrapolate that across to people who have funded vision coverage today, you save 1% of what the federal government spent on health care in 2009, and every percent counts. this is proof that we need to challenge the current way we provide health care and continue to look for innovative solutions like exchanging data between two parts of our health care system. now, it's my pleasure to introduce our keynote, the economics of health care. we will be joined by dr. david

cutler by harvard business school, dr. robert galvin of the blackstone group. we are delighted to have elizabeth cohen to moderate today's panel. she makes sure every #-b gets the help for them and their families and the book signing of the empowered patient today at lunch at 12:45 at the bookstore. let's welcome our great panel this morning. [applause] >> good morning, and welcome to our session. thank you for that introduction, and he mentioned my book, and i've been touring around the country for the last six months since it was released, and i tell stories about what happened to me and my family, good and

bad in health care, and it's very heart felt, and i go on for 20-30 minutes about our experiences, and then i ask for questions. always, the first question when someone raises their hand is so, elizabeth, what do you think about health care reform? good or bad? so what i get to say is i'm a journalist, so i don't have opinions, and then i ask for the next questions, but these gentlemen are not journalists, and they get to have opinions, so i figured we'd start right in, go down the line this way with your thoughts on the health care reform bill that was passed about a year ago. >> okay. well, good morning and thank you. you asked the question health care reform good or bad, and i will say good. let me offer -- i know that's a big surprise -- but let me offer a couple reasons why. the first is that it will finally give coverage to essentially all americans ab sent people in the country

illegally. almost all americans will have coverage, and it's hard to overstate the impact of not everybody having coverage. people are worried about can i change jobs, can i afford to move from one business to another, what if my spouse loses her job, will i still be covered? how will i make sure i get care? there's an enormous amount of economic uncertainty and economic or economic outcomes associated with that, so that's the first big thing, and then the second big thing is that the reform if we build on it the right way, i think it will lay the foundation for a very significant reduction in medical costs by rationalizing how health care works, and rather than give you any of the economics, i'll just give you one example. if you look at senior citizens, people on medicare who go into

the hospital, one in five of them return to the hospital within a month, one in five go from the hospital to the hospital within a month. in many cases they never saw a doctor, they never saw a nurse, and we know that in the best medical care systems, one in five becomes one in twenty, and the difference between the average medical care system and the best medical care system is that they have information so they know who is in the hospital, and then someone follows up. >> they never saw a doctor or a nurse during their initial stay? >> in between episodes. no one ever checks in. if you have a nurse come visit them within two or three days or a week, you go from 20% readmission to 5% readmission. you save tens of millions of dollars if you do that. right now, there's absolutely no incentive to do that in the health care system. no one gets paid for doing it,

nobody has it in their interests. what health care reform does is it says let's make things like that economically viable, and what we'll do, i believe, is we'll lay a foundation for making the right care at the right time to the right patient financially and lower the cost. i really think we have an opening here that if we follow through it will lead to very, very good changes, and i would like to be optimistic. >> great, thanks. >> yeah, thank you. i'm not an economist, so i do run an interest company representing 40 employers, and i send a lot of time over the last few months negotiating with both health insurer and providers, and i represent employers.

in answer to your question good or bad, i would say yes, it's good, and it's bad. when i speak to employers, everyone i speak to is happy about the uninsured problem being addressed. they think that's a positive, and every one of them wants it explained to them likes the framework of the iom and patient centeredness and quality. i think those are considered very strong and very good. no one i've spoken to on the employer side, however, thinks it's going to save money, and let me quickly say when you speak about employers, and i think the audience knows this, large is different from small. those who cover from those who are not, those in the health care industry itself, but philosophically they are bound together by some thoughts, and i think in the short run, employers don't find cost savings because they had to expand coverage and because certain individuals are going to pay more tax and because the

administrative savings of doing things that seem simple when in congress like reports of w-2s, covering people up to age 76 and those working inside the company understand what work that is in terms of just working with your payroll systems, tieing them to the benefit systems, ect., ect., but i think david would agree with that. it was a coverage bill at first, and then cost more later, and i think that's fair, and i think that's really the interesting topic, so i think when it comes to the longer run and on the cost side, you know, i was trying to think of two words as i talk to employers to describe what they thought about it and it began with shock and awe, but i thought that was not explanatory enough, so i think it's uncertainty and concern, and there's tremendous uncertainty that i cannot overestimate. there's uncertainty about what parts of the laws will happen. there's uncertainty about

exchanges in some states and not in others, and the idea that once again employers who have not had a deal in many years without a multisystem might have to because states have to do things above federal requirements, and there's uncertainty with insurers and providers as well. again, we'll finding as employers everyone is spending their time in strategy sessions trying to figure out what to do which takes the eye off the ball today of dealing with the problems and manage care more effectively. in the longer range, employers look at this and they kind of bounce it against their own strategy, and really everyone who covers health insurance on the employer side is going down a road of consumerism, of trying to get their employees to be engaged, and they are doing this through education, lots of information about providers, and they are doing it through

incentivings and benefit design changes. when you balance it up against there, you say really like those increased incentives you use on the premium side. that's a positive. on the negative side, a big missed opportunity in the terms of price because we think that to get people to be active consumers, quality is not unimportant to them, but it's a little bit confusing, frankly, and they tend to trust doctors in hospitals. price is very meaningful, and so we think there's a big missed opportunity there, and then when i would say the last comment i make is we believe there's a big underestimation of the impact of the public sector impacting the private sector. my colleagues don't believe in cost shifting, but i tell you someone who negotiates with hospital ceos and health insurer all the the time when you fund a

bill by medicare paying less, sooner or later the private sector pays more. when you tax manufacturers, sooner or later that comes here because medicare can't fix the prices, and the last thing, and i'll yield my time, but hopefully we can get to it is the idea of social reengineering that i think the bill is doing with accountable care organizations and others which i think, again, had some positive concepts but from very worry smit realities when it comes to employees. >> great, thanks. >> that's where i'm coming from too. there's great themes, but below the headline level, we have to ask is it going to work? does it really make sense? do the pieces fit together? i would argue that they don't fit together. they counterfeit together, the legislative process bit off more than the country can chew, and the legislative process did not have sufficient open

consultation with the health sector, with businesses, with everyone concerned, and really i think took on way too much. you'll find anybody in this country who would disagree with the idea that people ought to have health insurance. the question is how do you do it? you wouldn't find anybody in the country who disagrees with the idea -- well, maybe you would. maybe the people in this room. that there ought to be -- that health spending ought to slow down. outside of this room, there's plenty of people who agree with that, but how do you do it? ultimately, those are the questions that have been plaguing us for many, many decades. i don't believe that the health legislation that passed gives have many good answers, and i think the evidence of that, the sensible response from hhs is to start to give waivers where things clearly don't work.

the fact is that there are -- the themes we're talking about, in particular medicare, bob mentioned cost shifting and medicare cuts, what kind of cuts are there? the standard cuts that congress duped take. congress has steadfastly, except for the first year, 2003, has steadfastly refused to take cuts on physician payments. precisely because the cuts are swipe against not just physicians, but also perceived as a swipe against senior citizens, and they vote, so faced with those political realities, what can we really expect from medicare, and what should have been done? i think that's the question. essentially, medicare has been left to its own devices.

the money that is theoretically taken out of the program is recycled back into sub subsidies for non-senior citizens, whatever you think of that, the fact is that medicare is not made more secure by the price reductions to hospitals and other providers. the failure to deal with the physician payment problem is another issue. the administration wants to say that because the physician payment problem existed before, therefore somehow it's not part of health reform, well, it wasn't part of health reform. it's $350 billion over ten years that we'll have to come up with or we'll have to steal ourselves to the reality that those cuts in some form have to take place, so where's the hope in this bill at least with regard to medicare? it's with the innovation

center. it's with the dozens of ideas that are very much at the idea stage, that have yet to be proven. we can all be hopeful that those ideas will, in fact, jell in some way, and we can be hopeful they jell in the medicare program which is, in fact, the one leverage point the federal government has. >> does dr. cutler raise an idea? after a noble person is discharged, there's a nurse coming to their home after a couple days and that brings the readmission down to 5%. what do you think about that idea? it's a simple thing, just one example of many things that could be done. what do you think? >> there's the distinction of being the state with the worst record which is maryland, short term readmissions. there's lots of reasons for that, but certainly the failure for follow-up is a big factor. it's a failure on both sides. it's certainly the failure of

the health system. we don't have health systems that manage care very much in this country, and that's -- we should move in that direction. >> do you agree it's a good idea? >> that's a good idea, but to say that's what aco's will necessarily do is i think a leap of faith. >> let's leave aco's alone for a minute. do you think people in general agree that's a pretty simple good thing to do? send a nurse -- >> well, i'm not sure it's simple, but i think a lot of people agree that there needs to be contact. it doesn't necessarily require that the nurse go to the patient's home. sometimes a phone call, a quick follow-up after a day or two to listen to the patient tells you everything you need to know. it doesn't have to be expensive. >> why doesn't it happen? why don't insurance companies do that? >> well, i think a large part of it is that the payments are fragmented, and so one -- again,

the idea -- >> i get that part. i get that part, but if it clearly saves money, bringing readmissions from 20% to 5%, why not do it? if i'm an insurance company paying for someone's care, i'd love that; right? >> you might love that. how much money are they willing to put into the management which suspect considered under the new law to be part of the benefit, and i think the new law will limit many of these kinds of innovations to the extent they are considered administrative costs rather than benefits. >> yeah, look, so i too think it's a great idea. i think readmissions and unnecessarily readmissions to hospitals is a terrible thing. i like it. i agree with joe, but i'd like to say that's a bad thing, we're not going to pay for it, and then let different ideas emerge so whether it's e-mail to some people who want to get it, a phone call, or better discharge

instructions, however it works, it works, and the reason why it doesn't happen? that's a great question. you probably get asked that on your tours, and i don't think anyone can tell you. i can tell you that if you're an insurer with the hospitals, the hospitals say that's not what i do. in other words, this is not easy doing what i do. >> you mean sending a nurse out or calling? >> yeah. i take care of them, tried my best to give discharge instructions, that's all i do. i don't get paid for anything more, and it is a whole different set of schools that really suspect my thing, and that's why the idea of coordination is really important. i think it's how that gets done, you know, where david and i might differ some. >> now, he brought up that one simple thing that could save money and possibly save lives. the two of you, what's your favorite? if you were in charge, what would you do? name one thing. >> talking about similar to david's thing? >> yeah, that would cut costs

and improve care. >> look, i think the crux of changing the both of those is payment reform, and i think that is a type of payment reformment i think a second type of payment reform already instituted is unnecessary complications in hospitals. i think that clearly is something that should never happen, and our payment system -- no one tries to make that happen in the hospital, but the payment system pays for it. >> pays to repair the mistake? >> yeah, it pays for the procedure that was the mistake and pays to repair the mistake so i think that's another immediate payment reform that makes the same amount of sense as the unnecessary reason. >> hasn't there been action on that? >> yes. >> has that worked since they went on to fix it? >> too early to tell. >> yeah, and i'll tell you it's so easy to sit up here and say it. being a physician and having practiced intensely for 15 years and still seeing patients, it is

a wrong sided amputation is one thing. there's a couple things that are discreetly errors, but so many many that are so much more nuanced when in the heat of actually taking care of someone that it's going to be less than people think it's going to be in the end. it's still the right thing to do for egregious errors that should never occur. >> give an example that should be nuanced? >> certain kinds of complications kind of related to surgeries so, you know, we just had a friend of ours who had valve surgery, and now ends up with a lung full of fluid, so 98% of people that have that procedure don't have that fugs after they have the valve surgery. this person was sick, ended up in the intensive care unit. was there a leakage before, or

was this person's particular physiology and anatomy lead to it and it was something that was going to happen anyway? that's nuanced and complicated and a fairly common surgery, a valve surgery and a bypass. it gets complicated. in-house infections are not really complicated. those are preventable. >> dr. antos, do you have a favorite? >> let me expand on this a bit because it illustrates the clumsiness federal policy has. there's a list of dozen so-called never conditions. it doesn't pay for the things. >> never events. >> sire, yeah. >> just wanted to be sure. >> maryland has a different approach. maryland is the only payer rate settings for hospitals, and instead of picking 12 things that we care about that the

hospitals may have trouble dealing with or we may not fully understand, we have a much more complicated involved coding system, drg system, and so we have something like 80-90 conditions that we will not pay for. hospitals, these are 80-90 conditions we've identified that had some probability of being questionable, and we want you to work on them. you pick the things that you can do. don't pick the things you can't do. you work to improve your system. this is a huge difference, one the few i point to with pride, between the maryland system and medicare because it's the sirches between the payers saying i care about this and you have to follow my orders, and the payer in this case saying we care about a lot of things, you pick the things that are most

important and deal with this. having said that, this also illustrates where i be coming from in terms of innovation that's going to save money and improve health care, and that is we need a lot less micromanagement. the problem with micromanagement is people aren't at the scene, on the front lines, have theories about how things work. we call those people congressmen. [laughter] so, you know, they are often well-intentioned. i say often, but they usually don't know what they are talking about, and so we need to be able to move the decision making down, but without moving the control over the money down, so the fact is that having some kind of a system that puts real best of my budgetary constraints on spending is ultimately where

we have to go. >> a question from the audience, can you basically trust health care reform to people whose first priority is this is their wording, not mine, whose first priority is to get reelected? i mean, members of congress are not experts on this. they do have the goal of being reelected. love your thoughts. >> it's interesting because if you look at the medicare program, it's in many ways quite out of date as joe was saying and bob galvin. it doesn't do what it should have. one example, not paying for never events was an idea that arose in an oim report in the late 1990s, and throughout the 2000s in the bush administration, the department

of health and human services never acted on the recommendation even though they were wasting tens of billions of dollars a year, and if you asked them why they were afraid of congress, they were afraid that congress would yell at them, so there was a determination that having 535 ceos was a bit too many for the insurance plan, so what's interesting is one of the things the affordable care act does is it has a lot of secretaries. everyone heard about the 2000 instances, the secretary show. what those are doing there is saying as congress, this is the way we want the system to go, and you, you single ceo are responsible for carrying it out, and we're not going to try and micromanage it, and so my hope is that what that reform turns

into is a system where congress is at a broad level looking at what itments to do and -- it wants to do and broad policy and so on and at a detail level delegated it, and in return what the payment systems do, and if you come back to what bob and joe were saying, they say, look, we're just going to give you one price for the hospitalization and the readmission, okay? don't come to us needing more money. whatever you need to do to get the readmission rate down, you do it, but don't ask us for more money when the patient returns to the hospital. it's a way of delegating from the hospital to congress to the administration to providers saying you deal with the problem, we are not getting in your way. i'm hopeful that's the dynamic that plays out so that it really looks like a system where on the ground people are figuring it out. >> well, thank you. any questions you can e-mail

them to questions@worldcongress.com. let's move on to talk about aco's, accountable care organizations. do they exist? does anyone belong to them? they've been talked a lot about, but i don't know if i know anyone who actually belongs to one. you're laughing, you can begin. >> well, every medical practice in california seems to be an aco. you adopt the name first and figure out what it is later. >> you tell us. what is it? what's it supposed to be? >> well, i haven't had a chance to read the 300-odd some page regulations that came out a couple days ago. >> my version had 429 # pages. >> is it 429 pages? i'm not sure what cms -- >> i read most of it. >> you have, very good. thinking about let's say the --

aside from the relations that haven't been digested by the health system, what can we really expect aside from marketing? one of the ideas here is essentially managed care except a gentler care of managed care. if we can accomplish that, that'd be a great thing. >> we know managed care, but that's gentler? >> the contrast may be in the 90s, in the early 90s when a lot of employer plans, medicare moved very much towards traditional hmos, and mmo being -- hmo being an organization that you have to enroll in, and there was -- that form of managed care had a lot of mother may i's in it as well. if you were going to go to a specialist, you had to go through a primary care

physician. if you were going to be admitted to the hospital, you needed approval and so on. some of those ideas probably didn't work, many of them did. >> you mean, there were movies where characters made fun of it. it was a popular thing to -- >> right, that was unfair. by the mid-90s nobody wanted it anymore, and the reason was for the threat of the recession going away, business was good, employers were willing to contribute more to the benefit plan, and in the medicare case, congress had its own ventures starting in 1997 that pretty much undercut whatever the program was called at that time. what are we looking at now? well, some people think these essentially could be hmos without explicit enrollment, that people would be somewhat

assigned in some way that i don't understand, but depending on say which primary care doctor they go to, but they are not necessarily limited to the network of providers who are in that specific aco. that raises some interesting questions. first of all, if you don't know you're in a network, then how can the network manage its business? if you do know you're in the network, are you happy about it? i think given the state of the economy, people may, in fact, embrace the idea, especially if these networks have sensible managed care which i don't think we necessarily saw in the 90s. this is one of those experiments that remains to be worked out. >> you know, let me speak in defense of aco's kind of. >> can you define what they are? >> sure. keiser, group health, health systems in minneapolis. >> is it a closed hmo

basically? >> it's an organization of providers accountable for the entire spectrum of care for a patient, for an individual that is paid kind of in the best of worlds not by the drink, but on kind of a prepaid per person rate. >> when you write your check for the premiums, it goes to the same people providing you the service? >> not necessarily, but the payment still could go to an intermediary, but the payment from that intermediary to the provider system in its best form goes as a whole, so if you know anyone who belongs to cree, which you probably do, they belong to an aco. >> if i want to go elsewhere for treatment because i think there's a better person across the country, i mean, i suppose i could do it a mother may i, but basically i can't do that? >> exactly. this was not easy for hhs to try

to solve for this because the very thing that helps you manage care means you stay within the walls, the very thing our population is not ready to accept, restriction on choice. you know, that if i know or i'm told or my cousin who is a nurse told me that the absolute best person for this shoulder surgery is here, but it's not in my network, then i can't go, i think the population really doesn't like that. i think what cms is trying to solve for is kind of in between. they don't want to alienate people. on the other hand, they want to try to promote coordination. i think joe is right. i don't know or have an answer to it, but i do think that's going to be pretty tough to pull off. >> throwing something else that could get me in trouble. this is not my opinion, just an idea. if you are rich, you get a mercedes, if not, you get a

hyundai. if you are rich, go for it, enroll yourself in the program where you get the best surgeon. if you don't have money, you're in a system where you have here's the list, these doctors, and that's it because you're paying, obviously, these are made up numbers, $100 a year, and the guy paying $1,000 a year gets to go where he wants. we do that with other things, schools, groceries, we do it with all other things, why not with this? >> we do do it today, and it's the uninsured. the question you're asking is in the future, and david, you can have your word, is do we want to construct the system that way? >> and be clear about it. here's an aco, if you don't like that idea, i think we do do it, but not that clearly. >> within -- so you need to distinguish between medicare and private insurance. in medicare, the way that the

law is still written, you cannot deny a beneficiary of a choice of any provider. that's what bob said they are working around. if you look inside of medicare, in massachusetts, where i come from, small businesses are buying limited network plans, and what a limited network plan is is it has a set of preferred hospitals, let's say, so if you want to give birth, the preferred hospital is the mt. auburn hospitals. if you don't know you have a complication, then you pay $2,000 for that. not that you can't go, but you have to pay more for it. >> in advance as a premium or you mean -- >> at the time you want to go there, if it's not one of the preferred organizations, then you have to pay extra for going there. >> do people pay the extra? choose to pay it?

>> they are happy with mt. auburn. people will have seen here a recent study about blue cross-blue shield with an alternative quality contract where they give fixed amount to money to the provider groups. they run various clinics, okay, and they said we'll be responsible for managing the care, take the money and manage the care and every time someone's in the hospital, they deduct the cost they pay the clinic. the clinic realized they sent their admissions to the most companyive hospitals, and if it was across the street, they would save a lot of money, so that's what they did. took two-thirds of their 10,000 add admissions crude -- across the street. other than the very specialized services, you're not going to be very expensive hospitals, and

that's an example where in that case, i don't think they even charged the patient anymore for going to the expensive hospital. you can charge the patient, make the provider pay more, and you can do both, but one way or the other, that's a lot of what's happening in private insurance where medicare is going because they can't use the price mechanism at the patient level it's going to the provider level, so it will say, you are managing these people, and if you can get them to go to the better hospital, the one across the street and it's cheaper and you have a better relationship with them and you convince them it's as high as quality, you'll save a lot of money. if you keep them out of the hospital, you save more. >> there's a difference between medicare and its 45 million and employer-sponsored insurance with the 160 million, so i don't think there's any question that's the system we'll going to end up with. it's basically as this law as you know far beyond medicare,

but as it set up exchanges within the states, there's going to be an existential health benefit package, and they have the freedom above that to add mandates of their own or to have more benefits added. i think part of what the country struggled with is a two-tiered system where the lower tier is clearly getting health care. i think to the extent that there's now an essential health benefit package, a good thing coming out of the legislation, as long as that benefit package is going to be acceptable, which i believe it will be, i think you're now in a different game in terms of having a two-tiered system, which the country, although it has it, will feel better about saying it's okay. >> it's one thing to theoretically have an essential health benefits package and another thing to get benefits. with your animal sigh what car you buy depending on your

income, we also address if you have no money you walk, but what about the people who takes bus? in other words, medicaid patients. we're going to sub substantially increase the role of medicaid, and it's all the case that it's difficult. if you're a medicaid recipient to be seen by a a primary care physician or anybody other than a public hospital where you can spend a lot of time in the emergency room, so, you know, to talk about essential benefit packages without asking yourself is there going to be delivery is a major issue especially for medicaid because those are, in fact, the people we're not paying attention to. we are focusing a lot politically on the uninsured, and there's 20 million people who will be uninsured in 6-7 years for a lot of reasons, some them, some us. but medicaid, we solved that problem, that's what the

congressmen believe. it's gone now. especially in washington, the states will take care of it. i don't think they will because they've done a poor job so far. >> a question about gdp. what percentage of our gdp do we spend on health care? >> 17. >> about 17, okay. is 17 too high? is this too high? is 10% good? is 2% good? is there a magic number in here anywhere? >> 100% is the top. [laughter] and 0 is the bottom i suppose. economists don't think that any single share is the right number or not. what matters is what are you getting for your money? you may spend a lot on a car, and it may be worth it to you. the real question is not is 17 too much, but what level should we be spending given what we're

getting, and the -- that bulk of policy analysts think that we are overspending relative to what we could spend for the same or better outcomes, overspending anywhere from a third to a half, so that is we could be spending 10%-12% of gdp with roughly the same outcomes if we did it right. >> can i ask a dumb question from a noneconomist to economist? which is, suspect it possible if it -- let's say you are getting value, and it's unbelievable this is a healthy population. every town has hospitals and doctors, and it's 30% of gdp. doesn't it crowd out other things that we need to spend? that really is a legitimate question to be honest. >> right, right. the real question is that worth more than than whatever else?

the biggest problem is in the public sector where we are unwilling to raise money. suppose we had an incredibly proficient health system and the way to do it was to put everybody on medicare because it's the beacon of the health care system, and we refuse to raise the taxes to pay for it, and we crowd out everything else that's valuable, that's the biggest problem where we go into a recession, we cut massively because that's the only way to deal with it. in some global sense if we tax ourselves saying this is worth it, let's do it, spend the money there, it would be fine, but it's just a problem of, you know, both do we feel like we're getting our money's worth, and can we get the money to where we need it to be to pay for it? >> well, that assumes we know where we need it to get to be and it's up ahead somewhere, and that assumes an incredibly degree of efficiency not just in

the delivery of care, but in the sense that bob was talking about that people get what -- now, what is it? want or need? there's a really tough question in this country. is it want or need? i think there's a lot of want. there isn't necessarily a high proportion of need in all of this, and so what bob said i think is exactly right. you begin to -- whether it's efficient or not or whether we get value for it or not, you begin to close off other options. raising taxes also closes off other options. raising taxes is not a spur to economic productivity. it's a spur to government spending, and in the economy that we have not been enjoying for the last three or four years, you have to ask first not how do we spend more money for health care, well, again, maybe outside this room, but how do we get the economy going? how do we get the economy back

to the kind of growth that we once saw that we thought was normal? i don't think taxes are the way to go. once we get to that point, then maybe we can talk about taxes, but until then, it seems crazy to hobble us further. >> but isn't the problem that it's one person's want is another person's need? the same event can look different from two different people? for example, i know young people who hurt themselves playing tennis, and they want an mri of the shoulder. others say do physical therapy and you're fine, but the patient feels mri's are important. it's possible that mri could be a waste of money, but it's possible the mri could yield really important findings to help the patient. >> what happens if they pay for it? what happens if the answer to them is not because there's a shoulder problem, i examined it. you need physical therapy. no, i want an mri. that's great, here's the

choices, that's $1,000. it's your $1,000 to spend because that's the way the benefit assignments work. benefits show clearly the want goes back to need very, very quickly. >> you mean need goes back to want? >> whatever. >> the thousand bucks makes them say i'll do physical therapy. >> they don't need it, just wanted it. >> it makes them opt out. >> yes, it changes the balance between what want is and what need is. >> let's say, making this up here, let's say that person is not a person of great means, and they say, $1,000, are you kidding? i can't afford that. that's my rent or whatever. i'm not going to. i'll go with the physical therapy. six months later, thing are not well, there's an mri, and wow, man, if he had that six months ago, we could have seen the problem was x instead of y, and it would have been better to have that mri six months ago.

>> that's why we have evidence-based medicine and guidelines so although nothing is perfect, no one is treated differently because of what they afford or cannot afford. >> what's interesting is that in that scenario, he really did need the mri, and his outcome was harmed because he didn't get it because you asked to pay $1,000, but in the scenario the physical therapy works, it's a waste of money. >> i can answer that, but i'm taking up too much of the stage. there's means testing of what they with afford. those are the plans that make sure that the amount that anyone pays in any year is proportion to their income. >> i just want to cop trass two -- contrast two examples, the mri and the shoulder and then the hospital readmissions. the hospital readmissions has

the future that nobody is better off by using the care if you prevent it. the mri says maybe it's valuable or maybe it's not. whenever the president did a town hall about health care, the first question asked is the equivalent of the mri on the shoulder. it's if your mother were 88 and needed an expensive chemotherapy, do you want her to get it and so on. what most of the analysts or at least what i think is that when i said that we were overspending a third to a half, i think approximately a third to the half is closer to the readmission to the hospital and not the mri on the shoulder and that our first priority is to get rid of the third to a half. once we've done that, there is then this issue about the mri on the shoulder, the chemotherapy on the 88-year-old. as a society, we were unwilling to deal with that. that's what the death panels were about in august of 2009,

and i think the charitable interpretation is that people were saying don't confront me with that question until you've figured out how you are going to get rid of the readmission. >> in dollar-wise, what costs more? the admission issues or mri? >> readmission is much, much more. another example, rates of imaging in the medicare population has not changed. they tripled in the past decade. we had no sense they were too low a decade ago. we have no sense we're doing the right number now. if you look, you say, okay, i see the patient once a month. rather than any real sense about what's the right number, are you killing the patient by too many images? where the vast bulk of money, wasted money is i think in the stuff that you could eliminate and people could be better off. >> dr. aptos?

>> you know, every health service has a probability of being useful, ranges from 0%-100%. some are obvious, most of them, very few are obvious, most of them you are not sure about. one of the things that doesn't happen in the doctor's office is a frank discussion with a patient about what's the likelihood that that test is actually going to reveal anything? part of it is that a lot of patients come roaring in with someone else is paying for it, so i want the mri. some of it is that the doctor's worried about going to the next patient. some of it is that the doctor hadn't really thought about it and never gives patients any choices, so we've got problems in the way health care is delivered that make this problem very difficult to solve, and you can't solve it top down.

we need special societies, medical schools to get with it and recognize that it's a broader, psychological, a sociological issue than the mechanics of health care. >> you mean, the discussion that goes something like this with dr. galvin's patients. mr. smith, you can get the mri. this is what it costs you, personally, out of your pocket, and frankly, studies show that an mri is only necessary in this kind of injury 5% of the time. is there a chance the mri will help? sure. but there's a 95% chance it does nothing, and you forked over money for nothing. you mean that conversation? >> right. there's at least one physician in the country who does this, and then if the patient says, well, i guess i won't do it, then you have to get the patient to sign a note that says this has been explained to me and i

agree because of course the legal system then could cause a problem. >> i would have that same conversation, but start it by saying, mr. smith, you're going to be okay, and you explain to him and here's what happened to your shoulder, and i think good physicians do this. you take out a model and say this is what's going on. now, at the end of the day i don't believe you need an mri. the experts don't believe you need one, ect.. i think the right conversation in the right way. >> maybe it's cancer. maybe that's what's going on with my shoulder. >> there's an interesting thing about cancer. >> what do you say to the patient? >> anything's possible, but it's not likely, and so i would just say there's no reason to believe that that's possible, and you would try to talk to the person. again, i think that's why i like that little price there. >> yeah. >> they absolutely have the right to an mr, but there's no way that kind of an insurance

pool should have to pay for something that unnecessary that's outside of clinical guidelines and evidence. >> now let's talk about men and prostates. >> men with localized prostate cancer where in most cases it grows slowly and you don't need to do anything, but you can do surgery and radiation and so on. surgeons and radiologists are aggressive saying we have to radiate it or take it out. when you give patients ology the information, forget about price, when you just give them the information, show them testimonials from men and families and so on, people choose to be less aggressive than their doctors. they say, why don't i wait to see if it gets worse. i don't have to do this right now. the price would up that further, but, in fact, a lot of this people are knowing things. >> patient's pain thresholds are lower than the surgeon's. [laughter] >> you mean they will opt for --

>> it's obviously them getting sliced up and they really understand, they opt for the less enviesive. it's decision support, and you talk about that in your book, but i think that's the advance that you really do need to do, and one thing that joe said i want to speak in defense of primary care physicians because i am one, it really is the way that primary care physicians are paid. the fact that they have so little time to spend with patients, the fact there are not many of them anymore, i think the bill in a min ma'am way tried to do something about it, and it did, but if we are going to reconstruct the system, aco, not aco, you need a strong base of primary care physicians paid in the right way to have those exact conversations with parents. >> well, let's see, there's a question here. not sure i get that, do you guys

get that? i think guidelines, talking about evidence-based medicine. i get this now. this is a great question. you're in the room, dr. galvin, we'll start with you. how much of what your advising is based on your personal experience as a physician? you know, what happened to you yesterday, 15 years ago, and how much is based on studies you read that say someone is presented with this, this treatment usually works. >> you know, look, it's usually a come by in this combination. it's a great question about guidelines. ..

>> i think that development of those should be paid for. and physicians ought to be rewarded based on how closely they do not adhere to them. two caveats. one is there's so much about practicing medicine where there are no guidelines. we simply don't have the sciencl toy know. and secondly, patients are diverse. now we call it personalized medicine, and something we'veson always known.g so i think that we have toso follow guidelines that stillat allow professionalism andprofesi discretion to play a role and is estimateat is the balance. >> is that possible to follow the guidelines? i t arts those contradictory? >> guidelines are guidelines. they are not strict rules you must do this you may not do that and this is the tradition of modern medicine. this isn't a new idea. the specialty societies create the guidelines and continuing education and so on triune to

keep up with changes in technology it's a good thing to do. >> gentlemen, thank you so much. this is been an exciting and informative discussion thank you. [appla >> the c-span networks provide coverage of politics, public affairs, nonfiction books and american history. it's all of able to you on television, radio, online and on social media networking site. find our content anytime through c-span video library. we take see spent on the road with our digital bus, local content people. bringing our resources to your community. it's washington your way, the c-span networks available in more than 100 million homes. created by cable, provided as a public service. >> the senate gavels in shortly to begin the day with general speeches are at about 11 agencies take of a bill to repeal a health care long

requirement that businesses report all been to payments over $600. the vote on an amendment to require a study of the measure before it is implement it. final vote expected shortly before senators break before the weekly party lunches meeting. when senators return, they will resume work on a bill to continue innovation funds for small tech and research businesses. a number of amendments are pending including several unrelated to the bill. negotiations have stalled on how to handle those amendments. the house coming and also at this hour. they are working on isn't really be fcc's new broadband policy. the house is live on c-span. now live to the senate here on c-span2. the chaplain: let us pray. lord god almighty, how great and wonderful are your deeds.

bless today the many people who help our senators do their work. lord, we thank you for the many members of their staffs who help them succeed. we thank you for our pages and the significant work they do. we're grateful for those who work without fanfare to keep the legislative process going. keep these faithful servants of freedom from growing weary in their labors. remind them that their harvest season will come.

may they never forget that faithfulness is more important to you than success. guide them with the light of your truth until one day they will experience the joy of hearing you say, "well done." we pray in your great name. amen. the presiding officer: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. the presiding officer: the clerk will read a communication to the senate.

the clerk: washington d.c., aprill 5, 2011. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable jeanne shaheen, a senator from the state of new hampshire, to perform the duties of the chair. signed: daniel k. inouye, president pro tempore. mr. durbin: madam president? the presiding officer: the senator from illinois. mr. durbin: madam president, following any leader remarks there will be a period of morning business until 11:00 a.m. with republicans controlling the first half and the majority controlling the final half. following morning business the senate will proceed to consideration of h.r. 4, 1099 repeal, with one hour of debate. senators should expect two roll call votes around noon on the menendez amendment and passage of h.r. 4 as amended, if amended. we will recess following the votes until 2:15 p.m. for the weekly caucus meetings. we're working to reach an agreement on the small business bill, and we'll notify senators when additional votes are scheduled. madam president, i'm standing in this morning for the majority

leader reid who has been called to the white house for a meeting with the president and the leadership, the speaker and leadership in the house of representatives. the object of this is obviously to avert a government shutdown. i listened carefully to the prayer from the chaplain this morning. i don't know if we will need divine inspiration or divine interjection into this matter. but whatever it might take, i hope the people of goodwill can come to an agreement. we're close. i don't think it is good for us as a government or as a nation to see a shutdown of basic services that may inconvenience and cause hardship across america. i yield the floor. the presiding officer: the republican leader. mr. mcconnell: i suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

mr. mcconnell: madam president? the presiding officer: the republican leader. mr. mcconnell: madam president, today the chairman of the house budget committee, congressman paul ryan -- the presiding officer: a quorum call is in process. mr. mcconnell: i ask consent that the quorum call be dispensed with. the presiding officer: without objection. mr. mcconnell: madam president, today the chairman of the house budget committee, congressman paul ryan, is releasing a serious detailed plan for getting our nation's fiscal house in order. congressman ryan's plan would put us on a path to reducing the national debt. it would strengthen the social safety net so that we can keep the promises we've made to america's seniors. it will propose a way for washington to start living within its means.

and it will repeal last year's health care law which raised health care costs, lead to fewer jobs and which americans have rejected. congressman ryan is presenting a plan, in other words, to address our most pressing problems head on at a moment when the president and other democratic leaders simply refuse to do so themselves. he's doing what his constituents have sent him here to do. anybody can say that our nation's problems need to be addressed, but history will show that chairman ryan is one of those who actually stepped up to do it. and he should be applauded for that by people of goodwill on both sides. unfortunately, we already know how many democrats intend to respond to this plan. we've heard the spin already. in the absence of any solutions of their own to a looming entitlement fiasco and the testimony of countless experts on the fiscal peril we face,

democrats intend to use congressman ryan's plan against anyone who supports it, despite the facts. they'll try to scare the public by claiming it says things that it doesn't. they'll squander the golden opportunity we have right now to tackle the biggest problems we face in a bipartisan way, the way our predecessors did when the two parties shared power in washington, all in the name of having an edge -- an edge -- in the next election. frankly, it's shameful. americans would like their president and senators and congressmen to lead. they don't expect to us agree on everything but they expect us to work together when a problem becomes so pressing that cooperation across party lines is required. now is such a moment. the debt is at crisis levels, posing a threat not just to businesses and families planning for the future, but to our national security.

since the president has taken office, nearly three million americans have lost their jobs. as a result of the ongoing housing crisis, millions of homeowners are currently under water on their mortgages. the only industry that seems to be growing is government, and the only city that seems to be isolated from problems most americans face right now is washington. all at taxpayers' expense. the budget debate we've been engaged in in the past several weeks is a direct result of the fact that democrats in congress failed to pass one of their own for the current fiscal year. republicans had to step in and do it for them. and now six months into the current fiscal year, the president and democratic leaders in congress still have yet to produce a plan of their own. house republicans have produced multiple plans, including one that they'll offer today which funds our troops through the end of the year, keeps the government running and gets us one step closer to the level of spending cuts that even the

senior senator from new york has described as reasonable. unfortunately, democrats would rather take pot shots at these proposals from the sidelines hoping that they become unpopular with the public so they can benefit politically. they have completely and totally advocated their -- abdicated their responsibility. so i'd like to applaud congressman ryan not only for the energy and creativity and seriousness which he's brought to these issues, but also for his courage and doing so at a time when democrats in washington would rather sit on their hands. by stepping forward, he's forced a much-needed debate about the many crises of the moment. it's my hope that our friends on the other side recognize this effort for what it is: a serious goodwill effort to do something good and necessary for the future of our nation. and that for the good of the nation they'll join in in this effort at some point before it's

too late. now, madam president, on another matter, as i've traveled across kentucky over the past year, i've heard from countless small business owners who told me how burdensome the so-called 1099 provision in the democrats' health care bill would be to implement and how it could hamper their ability to create good private-sector jobs. i hope they're tuning in to the senate floor today so they can watch the vote on its repeal. this has been a hard-fought effort, and all of the credit should go to the junior senator from nebraska, my good friend, senator mike johanns. he has led this fight on behalf of the countless entrepreneurs and small business owners across the country who raised the alarm on this issue. so this is a big win for small business. importantly, it's also the first of what i hope are many

successful repeal votes related to the disastrous health spending bill the democrats passed last year. the more americans learn about this bill the less they like it. we hope we can respond to their concerns with many repeal votes like the one we're going to have this morning right here in congress. then we will replace it with the kind of commonsense reforms that will actually lower costs and encourage job creation. once again i want to thank senator johanns for his leadership and hard work on repealing this onerous provision. this is a classic example of a senator who list topbd his constituents -- listened to his constituents, developed a solution, won the support of his colleagues and doggedly pursued a course of action that led to today's vote. america's spweugss can thank -- america's small businesses can thank senator johanns for pushing this initiative across the finish line and i call on the president to sign it into law. madam president, i yield the

floor. a senator: madam president? the presiding officer: under the previous order, the leadership time is reserved. under the previous order the senate will be in a period of morning business up to 11:00 a.m. with senators permitted to speak for up to ten minutes each with the time equally divided and controlled between the leaders or their designees, with the republicans controlling the first half and the majority controlling the final half. the senator from louisiana. mr. vitter: thank you, madam president. madam president, america's illegal immigration problem is clearly, clearly way out of control. we can all agree that we desperately need to better protect our borders, ensure that only citizens and legal residents can be hired for jobs in this country and reverse misguided policies that serve as a magnet for further illegal immigration. today i'm introducing a bill that falls into that third category, to get rid of these magnets that encourage further

illegal activity. the bill would amend the immigration and nationalization act in order to change our current practice of granting automatic citizenship to the children of illegal aliens born on american soil. when it comes to u.s. citizenship, it's not just where an individual is born that matters. at least it shouldn't be. the circumstances of a person's birth and the nationality of his or her parents are of at least equal importance. and i simply don't believe that our constitution confers citizenship on children who happen to be born on u.s. soil when both of their parents are foreign tourists or illegal aliens. the constitution does not mandate or require that. and yet, that's our policy. each year 300,000 to 400,000

children are born in the united states to at least one parent who is an illegal alien or a foreign tourist. a significant subset of that number includes children born to two parents who are not u.s. citizens, that category that my bill attacks. despite the illegal status of foreign citizenship of the parent, the executive branch, our government, now automatically recognizes these children as u.s. citizens upon birth. now, this practice is not mandated by federal law or the constitution. it's based on what i believe is a fundamental misunderstanding of the 14th amendment of our constitution. and as such, this policy is incompatible with both the tax and legislative history of the citizenship clause. i don't think the 14th amendment grants this birthright citizenship to children of

illegal aliens. in fact, all we have to do is look at history and the actual text of the constitution as our guide. the 14th amendment doesn't say that all persons born in the u.s. are citizens, period, end of story. it states that citizenship extends to -- quote -- "all persons born or naturalized in the united states, and subject to the jurisdiction thereof." close quote. now, this latter phrase is important. it's conveniently ignored or misconstrued by advocates of birthright citizenship, but of course a fundamental role in terms of constitutional interpretation is that words are assumed to be there for a purpose, and if those words had no meaning, had no impact, then the founders would not have written them in to that part of the constitution. its original meaning refers to

the political allegiance of an individual, and the jurisdiction that a foreign government has over that person. that's why american indians and their children didn't become citizens until congress actually passed the indian citizenship act of 1924. i'm introducing today's legislation because it's apparent that congress must reassert its plenary authority over naturalization and make clear that -- quote -- "subject to the jurisdiction thereof" close quote -- does not include children born in this country to illegal aliens or foreign tourists. those parents are clearly subject to the jurisdiction of foreign governments. my bill limits birthright citizenship to individuals born in the united states to at least one parent who is a legal citizen, a green card holder or an active member of the united states armed forces. congress clearly has the power

to determine that children born in the u.s. to illegal aliens are not subject to american jurisdiction. as judge richard posner of the seventh circuit court of appeals held in a 2003 case, -- quote - "congress would not be flouting the constitution if amendedded the immigration and nationality act to put an end to this nonsense." close quote. that's exactly what my bill would do, put an end to this nonsense. closing this loophole will not prevent anyone from becoming a naturalized citizen. instead, it will ensure that he or she has to go through the same process as anyone else born of foreign national parents who wants to become a united states citizen. now, our practice of birthright citizenship is clearly an incentive to illegal immigration, and it really does a disservice to every would-be citizen who is actually

following the rules, applying to be naturalized. standing in line often for a very long time. this misguided policy of birthright citizenship not only undermines the stability of our immigration system, but it has severe fiscal consequences as well as serious national security implications. recent news reports of -- have highlighted the growing popularity of what is known as -- quote -- "birth tourism." close quote. websites actually advertise birth packages for foreign visitors so that pregnant women can give birth in the united states and ensure automatic citizenship under current practice for their newborn children. and, of course, with that automatic citizenship comes the full benefits thereof, including unlimited travel to the u.s., educational benefits and the ability to settle here as an

adult, and eventually down the line, the ability to grab back the parents and get them into u.s. citizenship. one such agency that appeals to foreign mothers-to-be by describing the benefits of american-born children, pointing out that a one-time investment in a birth package will result in a lifetime of benefits for their family, was in the news recently, and specifically it says your children will be able to attend u.s. public elementary schools and that they may apply for scholarships designated for u.s. citizens, and they're entitled to welfare benefits. all of this explicitly spelled out in the advertising for this agency. just last month, authorities in california shut down a make-shift maternity clinic after discovering 10 newborns and a dozen chinese women who paid as much as $35,000 to travel to this country to give

birth to children who would automatically be recognized as u.s. citizens. now, birth tourism, as amazing as this is, is not a new phenomenon, as women from other countries have long traveled to the u.s. locally on tourist or student visas and given birth while here. however, recent reports indicate that the practice has escalated. a new report by the center for immigration studies finds that every year, 200,000 children are born to women who were lawfully admitted to the united states on a temporary basis. each of these children receive u.s. citizenship, despite their mother's allegiance to a different country and even if the father is not a u.s. citizen. birth tourism is certainly a reprehensible practice, but it's not an illegal one. it's astounding that the u.s. government allows individuals to exploit the loopholes of our

immigration system in this manner, and it's obvious that congress has the authority and the obligation to put an end to it. in addition to this birth tourism -- and by that, i refer to focusing on tourists here legally under a tourist visa -- of course, there are tens or hundreds of thousands of children born in this country to two illegal immigrant parents, and those children under the same practice automatically become u.s. citizens. and this, too, is a very dangerous practice, a magnet to attract more and more illegal activity across the border when we say we want to do everything to stop that. well, certainly, if we truly want to do everything we can to stop that, we need to unplug those magnets. stop that policy from attracting

more and more illegal crossings across the border. the presiding officer: the senator has reached his 10-minute limit. mr. vitter: madam president, if i could ask for 30 additional seconds? mr. inhofe: i object. madam president, i was scheduled for 10 minutes immediately following the senator from louisiana. if he would amend his u.c. to include my 10 minutes, full minutes following him, i would not object. mr. vitter: i would be happy to do that. the presiding officer: without objection. mr. vitter: thank you, madam president. so i introduce this important legislation today, and i thank senators paul and lee and moran for joining me in addressing this critical issue. i invite all the members of the senate to join me in doing this. and i -- i yield the floor, madam president. mr. inhofe: madam president? the presiding officer: the senator from oklahoma. mr. inhofe: we hear a lot about the disaster, the things that are taking place and the loss of lives in libya and many other places, particularly the last few months, with you going

seemingly unnoticed is probably just as great a disaster that's happening in coat did a -- cote d'avoir as we speak. the incouple dent president gbagbo was claimed by quattara. he comes from the north, the muslim area up there. we found so much voter fraud that we identified, we specifically talked about on the senate floor that i have asked secretary clinton by letter twice to intervene and demand a new election. when i say voter fraud, i entered this in the record yesterday, so i won't do it again today, but this shows how they miscalculated all those votes up in the north. in just one precinct, a thousand votes. well, actually, 94,873. now, obviously, if we have

100,000 or so votes in one precinct, it can happen that way. use logic. if all else fails, stop and think about this. how could it be possible that in the northern part of cote d'ivoire, that when they had the election, what we would call the primary election, president gbagbo got thousands, thousands of votes in each one of the precincts, and yet when the runoff came, he got zero. that is a statistical impossibility, and i think for those of us -- certainly the united states thought the u.n. and perhaps france was accurate in their initial response to this thing that we were going to have to get something done. let me go ahead and finish what happened. i mentioned yesterday. in the town of duekoue, with a quattara's forces along with the french went in there and murdered something over 1,000 people. we get the reports from the red cross and from other sources, but when quattara has tried to

deny his involvement in the slaughter, his forces took the town earlier, and this is a week after the gbagbo forces had gone. and i think we could just look at the deputy head of the united nations mission in cote d'ivoire, he said that quattara's forces had carried out the killings in duekoue. -- quote -- "we have evidence, we have pictures, this was retaliation." and so we have all this evidence that i mentioned yesterday was a part of it. i read yesterday from "the guard ran," the british guardian, the u.s. mission has tara dicials hunters fought alongside quattara's forces and took part in killing 330 people in the western town of duekoue which we now know is over a thousand people. the international committee of red cross said at least 800 people. it goes on and on, which i made a part of the record yesterday. but in addition to that, we have a statement that was made in the

bbc yesterday. keep in mind now, they have in duekoue, they murdered all these people, they have mass graves. people are charred and burned. i will quote right now. hold your stomachs." i spot four pigs eating something dark and charred in the courtyard, standing by a newly dug mass grave. a u.n. soldier from morocco is choking with rage and grief. i ask him if the dead are children. he nods and begins to sob quietly into his facemask." so we know of this disaster that is taking place, and here we do nothing, and we know about it. and i just would say america, wake up. the massacre could have been avoided if quattara had accepted the mediation effort from the african union. president gbagbo did accept, quattara did not, and he rejected it, and i think we know why he rejected it. because he wants that power, he wants that job. well, anyway, where we are now -- and i'm going to try to get this all in -- the united

states i think should call for the cease-fire and for a new election. i have also been told within the last day that the united nations helicopters, u.s. peacekeeping helicopters are firing upon gbagbo's military camp. lastly, i have sent a letter to the foreign relations committee chairman john kerry. let me applaud john kerry. he has agreed to hold a hearing to look at this. i can't tell you how much i appreciate it, because it takes courage to stand up against the united nations and france and our state department and admit that we have to look into this thing. so that's exactly what we're going to do. but that was yesterday on the floor. what happened last night? last night, the job was finished. they went in and they massacred i don't know how many people. you see, president gbagbo had young children that were surrounding his palace and his

residence, and his willingness to sacrifice their lives to save their country from the french influence that they are getting with quattara. they were armed with baseball bats and two-by-fours. i don't know, there are hundreds of them out there. last night, sarkozy went to the -- had gone to the secretary-general mune and said use my forces to end this, and they did, and we know what happened last night. maybe you don't know what happened last night. they went in with helicopters and with rockets, and they destroyed most of a town, of a major city, abidjan, the capital of cote d'ivoire. and -- and we have evidence. i hope that people will take advantage of this, particularly those people. i know there are a lot of people out there that are just opposed to any intervention that we have, and they don't really care about sub-sahara africa. no one cares about sub-sahara africa. i have stood on this floor time and time again, back when we were sending troops into bosnia. the excuse was ethnic cleansing. i said for every one day, and

any town in, any country in sub-sahara africa, there are more people ethnically cleansed than any day in bosnia, but nobody seems to care. so we have hundreds of kids around there, and last night they were mowed down. if anyone questions this, you can access on my internet, inwho have.senate.gov and get the youtube that shows graphically what they are doing. i don't know how many hundreds, how many thousands of people have been brutally murdered last night by the french-supporting quattara, and it's something that we need to get involved in, and i am -- when i look at president obiange from ecuadorial guinea, the chairman of the african union, he says he condemned the foreign intervention in the ivory coast. and we stand by idly and we don't do anything about it. so, again, i'm going to renew my request to secretary clinton and to the state department and to others who really care about the

loss of innocent life in sub-sahara africa, specifically in abidjan and cote d'ivoire to come forward and help us in this hearing to find that justice is done. i hope that president gbagbo and his wife simone, good friends, i hope they are not dead today. they might be dying as we speak. they are raiding their residence, they are raiding the palace, and it's a brutal mess. so i don't think i have ever seen in the years that i have been here, particularly coming from france, supported by sarkozy the raid on innocent lives in sub-sahara africa. and with that, i will yield the floor. if no one else comes in, i'm going to talk longer. all right. i ask unanimous consent that i be permitted to speak until someone comes in to speak. the presiding officer: without objection. mr. inhofe: madam president, i guess you might wonder why i am concerned about this.

i have had an interest in sub-sahara africa for quite some time, and after 9/11, finally the united states of america decided they would do something of concern in sub-sahara africa, and so what we have had since that time is an interest in helping them to build african brigades as the terrors come -- terrorists come down through the horn of africa and jabudi and the couldn't tent of africa. we need to help the africans build brigades so we can resist them, not doing it for them, not doing it in place of the africans doing it, but to help them so they can defend themselves. that's exactly what we have been doing. i have been honored to be kind of the point man on the armed services committee and to go over and work with these guys. our countries in africa are our friends. they participate in programs like the imet program that allows us to train their officers in the united states of america, like the train and

equip program that allows us to work with them and train these individuals. and so when you see something, an atrocity like this that takes place and you just visualize the young kids that are out there being brutally murdered, it's something that we should do something about. i again am going to praise someone who philosophically -- i have not agreed with most of the time i have spent in the united states senate and senator john kerry, and he is very -- john kerry, and he is very sympathetic to what is going on there and has agreed to having a hearing. there is a man named mel tiadora. mel tiadora was the mayor of and january -- abdid i january in -- abdijan in cote d'ivoire. he is the heads of the opposing

party to president gbagbo. he was the candidate against him when he ran for president. here is a guy who has every reason to be opposed to president gbagbo. yet he is willing to testify before senator kerry's committee that not only did they rig the election, but -- and showed the documentation on rigging the election, that we should be in a position where we could strongly recommend that we have a -- that we recommend another election. i have nothing against what you you -- guaterra except i know he has been an enemy of gbagbo since 2002. this is the final kill. at what expense is this coming? at a high expense of a number that we can't quantify today. if you don't believe it, look it

up you can get the youtube site and watch what happened last night and watch it on inhofe.senate.gov. i see my good friend, senator manchin, a new senator from west virginia, before i yield the floor to him, i want to applaud him for his being courageous and standing up for doing something about the e.p.a. taking over the regulation of greenhouse gases that would put coal and oil and gas out of our reach in this country. so i applaud you, senator manchin, and i yield the floor. the presiding officer: the senator from west virginia.

mr. manchin: i want to talk about the occasion of the worst mine disaster in 44 years. a year ago today men went underground to mine the coal of our great nation and they didn't come back. our entire nation grieved with their families for their tremendous loss and i rise today to honor their courage, sacrifice and the extraordinary strength of their families. i want to say a few words about the proud men and women today who go underground and go unrecognized and make sure our great nation can keep the lights on. when some people see a coal miner walk out from underground, they see someone who is tired, wearing dust-covered overalways, steel boots and carrying a dinner bucket and make a few flawed assumptions about the amount of education they may or may not have or they have nowhere to turn because there is

no job available. i want everyone to know those assumptions are dead wrong. west virginia coal miners are the backbone of this country, providing the lights for this chamber, the steel and machinery that build our country, the greatest industrial power in the world, the military that keeps us safe and free and energy for homes and businesses all over this country. west virginia miners understand geology, mathematics and physics, the way a seam runs through the earth and how to safely extract its bounty to make our country stronger. west virginia miners are the salt of the earth, patriotic, god-fearing, family-loving and family-oriented and proud of their hard work. in our state we've always done the heavy lifting. we're very proud of what we contribute to this country and time and again in times of war, times of peace and in times of prosperity and in times of need. at a time when our nation's attention and misplaced pity will again focus on coal miners because of the first anniversary of the worst mining disaster in

the last 40 years, we west virginians want the world to know that we are proud of our coal mining heritage and our future. as west virginia's former governor, now u.s. senator, i want to tell the americans not only about our sacrifice but also our dedication to our shared future. the miners of west virginia and their families are the heart and soul of west virginia and an inspiration for me and to my family. we should all draw strength from their courage that they have shown us all. now allow me to turn to the terrible day a year ago and remembering the upper big branch disaster, my thoughts turn first to the families of the 29 miners who went to work that day on april 5, 2010, and didn't come home. in the days following the violent explosion which remains under investigation today, i spent all day and every day for five days waiting to find out with the families if their loved ones were alive or dead. those families and i stayed

together at midnight and at dawn, through phoepls of -- through moments of hope and despair on pins and needles and in shared grief as the rescuers didn't find more survivors. we prayed together before and after each briefing. we recited the pledge of allegiance. we held each other and cried together. restaurant owners donated food. and one young man, nick helms, who i remember so well, whose father was killed in the sago disaster in 2006, came down and offered firsthand his experiences. in those days the unbreakable bond of family became very clear. one family alone lost three good men. i first told charles and linda davis, the parents of timmy and the grandparents of corey and josh, i told tommy -- and tommy was another brother who worked

in the mine, just came off the shift, and tommy was the father of corey. and i also told patty -- large families -- and patty is the daughter of linda and charles. she was josh's mother. so we had in the mine we had timmy, the uncle; and we had josh and corey. all three men had been found, but they had perished. the first question i got from tommy after i told his parents, he said, joe, were they all together? i said, yes, they were tommy. tommy replied to me, he said, i knew my brother timmy would be taking care of the boys. that was not my state's first mining disaster or mine. when i was a young man, my own family went through the tragedy of the farmington number nine explosion in 1968. 78 miners were killed that day, and it left a searing impression on me. of course we didn't know right

away how bad it would get. everyone camped out at the company store. we were all waiting for any word before the authorities finally came and they told us all that the decision had been made to seal the mine, which essentially was entombing all of them and the rescuers over. in that disaster i lost my uncle, i lost my next-door neighbor, i lost some of my high school classmates. one of my strongest lessons that has stayed with me to this day is that waiting families should be systematically updated on the progress of a rescue operation. i know firsthand that a minute seems like an hour, an hour seems like a day, and a day seems like eternity. with consistent updates, the waiting becomes a little more bearable. during my term as governor in the thraoel tragedies we went through -- three tragedies we went there, sago and upper big branch and saracoma.

we received a briefing every three hours. it was a cycle we continued until the fate of all of our miners were known. we've learned a lot in west virginia after disasters at sago and eracoma. we enacted more safety measures in my term as governor than in the 30 years before. we've become a leader in safety. what we implemented is being used in all types of mining all over our country and around the world. the bottom line is in our state we won't tolerate intimidation from any person or company that puts profits ahead of safety. and i truly believe that the single-most important element in any mining operation is the men and women who work there every day. under my watch, we empower those individual miners and their families to take more ownership and control over their own safety, without fear of retribution, with a 24-hour anonymous hotline to report

unsafe conditions. since may of last year we've had 86 calls and we responded. at the end of the day the families and the people of west virginia and all americans need to know how this tragedy happened and what we must do to prevent anything this terrible from happening again. we are still waiting for the results of the federal and state investigations as well as an independent report from my special-appointed investigator, jay mackaveerer, a west virginia native. we will look at the results of their investigation to determine what happened, make certain it doesn't happen again and determine whether anyone through intimidation or otherwise puts profits ahead of safety and that the people responsible are held accountable. in the meantime, i am cosponsoring a piece of legislation with senator jay rockefeller, the robert c. byrd mine and workplace safety and health act of 2011.

it is designed to improve compliance with existing mine and occupational safety and health laws, empower workers to raise safety concerns, prevent future mine and other workplace tragedies and establish the rights of the families of victims of workplace accidents. last week i spoke again to tommy davis, the man who lost his brother, his nephew, and his son at the upper big branch mine. when i asked him what he was doing these days, tommy gave me a simple answer. he said, joe, i'm back in the mines. tommy's proud to be a miner. and while he and all of us have much to mourn today, we also have the chance to honor the memories of the 29 dedicated men who died a year ago and their colleagues who continue their work with respect and dignity. finally, gail and i and all west virginians pray for continued strength and courage for the families who lost loved ones on this sad day a year ago.

may god bless each one of them. may god bless the great state of west virginia, and may god continue to bless the united states of america. thank you, madam president, and i ask the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

quorum call:

quorum call:

mr. menendez: madam president? the presiding officer: the senator from new jersey. mr. menendez: i ask unanimous consent the call of the quorum be vitiated. the presiding officer: without objection. morning business is closed. under the previous order, the senate will proceed to the consideration of h.r. 4, which the clerk will report. the clerk: calendar number 16, h.r. 4 an act to repeal the expansion of information reporting requirements for payments of $600 or more to corporations and for other purposes. mr. menendez: madam president? the presiding officer: the

senator from new jersey. mr. menendez: madam president, first, i ask unanimous consent of the following staff of the finance committee be allowed on the senate floor for the duration of the debate on h.r. 4: andrew fishburn and eric roberts. the presiding officer: without objection. mr. menendez: i rise to call up amendment 284 cosponsored by senators kerry and rockefeller which is at the desk and ask for its immediate consideration. the presiding officer: the clerk will report. the clerk: the senator from new jersey, mr. menendez, for himself and others, proposes an amendment numbered 284. mr. menendez: madam president, i ask unanimous consent that the amendment be considered as read. the presiding officer: without objection. under the previous order, there will now be 60 minutes of debate equally divided and controlled between the two leaders or their designees. mr. menendez: thank you, madam president. i understand senator baucus is on his way from a meeting. in the interim, i'll start off and recognize myself. madam president, i offer this amendment on behalf of middle-class families and on behalf of small businesses.

now, i support repealing the 1099 reporting requirement and have in fact voted no less than six times on this floor to repeal 1099 in this body. but i strongly believe that we must do so in a manner that does not increase the burden on our small businesses and their employees, and that is exactly what i fear h.r. 4 does. the broad bipartisan support for 1099 repeal comes from the fact that it provides relief to small businesses. but the only problem with this version of the repeal is that while it provides relief on one hand, it may very well take it away on the other. it repeals the 1099 reporting requirements, but at the same

time i am concerned that it increases the health care burden on the very same people we are seeking to provide relief to. now, some have argued that we have already used this very same offset before. we have, but there's no reason -- and so, therefore, there's no reason to be concerned now. the difference is, however, h.r. 4 is very different than what we did four months ago, and it risks driving up health insurance costs and cutting health insurance coverage for small businesses and middle-class families. it increases tax penalties -- tax penalties -- as we approach april 15, i know we're all very tax sensitive. it increases tax penalties on middle-class families, leaving

some with a potential tax burden of $10,000 or more. now, how would most middle-class families deal with a tax bill of $10,000 or more just because their income may have increased $1 above 0 the eligibility during the year they got a subsidy? now, some have also argued that my amendment will block implementation of the 1099 repeal. that is just factually incorrect. it is an outright misstatement of the facts. my amendment simply directs the secretary of health and human services after -- emphasize after -- the 109 repeal passes into -- the 1099 repeal passes into law to study the offset in h.r. 4 and determine its effect

on small businesses. if the study finds that the offset increases health care costs or decreases coverage for small businesses, then current law on the repayment remains in effect. if the study says that no, it didn't do any of those things, then there is no harm. let me be clear, we all want 1099 repeals. my amendment does not in any way affect the repeal of 1099. you can be -- vote for this amendment and for h.r. 4 because this would repeal 1099. the only potential change my amendment makes would be to the risky offset in the underlying amendment, and only if the study finds that it hurts small businesses after the repeal has taken place. my colleagues on the other side of the aisle are trying to frame

this debate as either for or against small business, but they are, in my mind, both helping and harming them at the same abltd -- the ability to help small businesses, but we can also ensure that small businesses and their employees will not get hurt at the end of the day. now, for those who may consider opposing my amendment, think of this: on the one hand, if you do not believe that this offset will hurt small businesses and their employees, there is no harm in voting for it, because you're saying the study will not show an impact, and the offset will remain in place. however, if you believe that my amendment would have a revenue score, you are assuming that the offset hurts small businesses

and their employees. either option would argue for supporting my amendment. either it has no impact, in which case there should be no problem supporting it. or it provides protections for small businesses and their workers, in which case you should want to support it. now, i realize that what i am concerned about as the harmful effects of this offset provision won't hit small businesses until 2015, and i know the voices for 1099 repeal are much louder than those against the payback tax, but i also know this is an issue that we will hear about when our constituents get those tax bills at that time, when this provision goes into effect and taxpayers get that first big big $10,000 or more surprise on

their tax bill. you want to be on the record as having given them the tax bill, or do you want to be on the record as trying to have saved them from this and save rising costs for small businesses and their health insurance? i think you want to be on the side of this amendment and having saved them from it. so in closing, i would ask why in the world, especially during these fragile economic times, would we want to do anything, anything that could raise the costs on small businesses? that's why my amendment is supported by entities like the main street alliance, a pro-business organization, families u.s.a., the american cancer society, cancer action network, health care for america now, just to mention a few. with my amendment, we can protect those who earn a living making our nation's small businesses run and repeal 1099 without delay. to me, that's the ultimate show

of support for small businesses, madam president, and so i urge support of my amendment, and with that, i reserve the balance of our time. the presiding officer: the senator from utah. mr. hatch: madam president, i'm going to defer my remarks until after the distinguished senator from -- from nebraska speaks. now, i want to defer to this wonderful senator because he has done more than any other person at trying to repeal this awful tax provision, this 1099 tax increase provisions, and he deserves the credit, so i would like him to lead off here in our debate, and then i will speak probably after the distinguished chairman of the finance committee. so i'd -- i would yield the floor to the distinguished senator from nebraska. the presiding officer: the senator from nebraska. mr. johanns: madam president, i -- i wish to start today by thanking the distinguished senator from utah for this courtesy. i appreciate it immensely.

it's been a bit of a long and tortured process to get here today, and so i really appreciate the opportunity to speak first. all of us, madam president, work across our states. i think of communities like carney, nebraska, scottsbluff, nebraska. i walk those streets often, whether it's a parade or just calling on people, and i'm struck by the number of small businesses that fill the storefronts and communities all across nebraska. these businesses are the heart and soul of the community. they contribute to the little league. they give high school students their first jobs. they ask how are the kids doing when you stop in to see them. they symbolize what it truly means to be a community. they also symbolize the single most powerful job-creating force in our world.

64% of the new jobs in our nation are created by small businesses as they expand and they grow. so when their livelihood is threatened by ill-advised policy, well, we all in the senate agree that something must be done. shortly after the health care bill was passed, i, like my colleagues, began hearing from small business owners who were very concerned about a provision that was put into the health care bill at page 737. as the number of concerned job creators continued to mount, i knew and others in the senate knew that we had to do something about it. passing 1099 repeal exemplifies why i came to the united states senate. taking an issue that is important to our state and to our country and literally building support here in this body to do the right thing.

i won't deny that there have been some frustrations along the way. i certainly didn't expect to have to present the legislation seven times to get to the finish line, but i will also say it's been well worth the effort, and i could not be more pleased by the bipartisan support that is built in this effort. today presents an opportunity for members of both parties to unite behind doing the right thing for our job creators. if we pass h.r. 4 and send it on to the president's desk today, it won't be a victory for republicans or democrats. i certainly won't report it that way. it's not going to be a victory for a single senator, but it will be a victory for millions of small business owners who have been begging us to do something about this provision for a long time now, and it will be a victory for common sense.

that is why today is such an important day here in the senate. in a few short minutes, we will have an opportunity to put to an end the looming 1099 paperwork mandate once and for all. small businesses in my state and all across the country are depending upon us today to act. one real-life example came from a nebraska company. it's called hayneedle. it's an online retailer of home furnishings and other home products. with the new 1099 requirement, hayneedle estimates that the annual cost of compliance is literally going to exceed exceed $100,000 for them. $100,000. madam president, that would go a long way to hiring more people. adding insult to injury, the 1099 reporting requirement

creates a perverse incentive to consolidate suppliers. few suppliers means less 1099 paperwork. this leaves main street's small suppliers, those businesses i was talking about, well, they're just out in the cold as big suppliers win more and more business. dale black, a kentucky fried chicken franchise owner from grand island, nebraska, told me, and i'm quoting here, "i want to be a good corporate citizen in the communities i have restaurants, but the 1099 forces me not to hire local vendors and tradesmen in my community, instead giving work to a single regional contractor." unquote. and with 40 million businesses, nonprofits, churches, and local governments bracing for the 1099 after latch of -- avalanche of

paperwork, well, every senator could come to the floor today and tell similar stories. with all these main street businesses and their workers hanging in the balance, there really is just one clear choice today. we must advance the house-passed version, and in all due respect to my colleague from new jersey, reject the menendez alternative, the menendez amendment. you see, only the house-passed version will quickly reach the president's desk and provide immediate relief to our job creators. you see, adding anything on, passing anything else, will cause our job creators to wait on the sidelines yet again, because then, of course, we will have different versions, a house version and a senate version, and i fear we go off into never- neverland.

but, you see, time has run out on our job creators. when this debate began, the mandate seemed a long way away. it was out there on the horizon. we had a long time to work through these issues, but now eight months have passed, we voted over and over again, and we never quite could get to the finish line, but it's decision time for businesses. they're feeling the pressure to set up the accounting systems they'll need to comply with this tangled mess of tax forms that even the i.r.s. doesn't support. this mandate forces many to set aside money for software that could instead be spent on those new workers, and that why it is so important that the senate passes the house bill today. put simply, a vote for the house bill is a vote to actually solve the problem, but again, in all due respect to my colleague from new jersey, the amendment tells our small businesses that they

will have to wait longer. our path actually gives our job creators some certainty they need to grow their businesses, but the other path, as i said, is a guaranteed sidetrack back into never-neverland. while one approach tells small businesses we're with you, the other says we're going to continue to work through this and wrangle back and forth instead of enacting a bipartisan solution today. now, the house of representatives has already led by example, and it's important to recognize that they passed their 1099 repeal on march 3, more than a month ago, and it got great bipartisan support. 314-112. 76 democrats voted for that repeal. not only does this legislation pay for the repeal of the 1099 mandate, it actually reduces the

deficit by $166 million over the next ten years. it requires repayment of improper health exchange subsidies, a concept the senate passed unanimously in december to pay for the doc fix. if we fail to pass the house version today, well, job creators are being told that they have to divert more of their resources to managing unnecessary paperwork. so let's not vote for another alternative that's just going to stall this out again. let's cast a vote today that sends a clear message. let's defeat the pending menendez amendment, and then let's pass the bill so we can get it to the president and get it signed. i'm hoping that this will be a strong bipartisan support, and i

just want to say again that the victory today is not for either party, it is not for a single senator. it is for the job creators who are depending on our action today. thank you, mr. president, i yield the floor. a senator: mr. president? the presiding officer: the senator from montana. mr. baucus: mr. president, my colleague from new jersey has proposed what i think is a very reasonable amendment to the revenue provision of the repeal of the 1099 provision, and i -- i accept it, and i plan to support it. i think it's a very good amendment. one of the key provisions in the affordable care act is a tax credit that will be available to millions of middle and low-income americans to madam chairman health insurance if their employer doesn't make health insurance available. that's a credit that goes to middle and low-income americans. the provision that will pay for a feinstein repeal will

increase -- a 1099 repeal will increase the amount that many americans have to pay at the end of the year if they receive a credit to purchase their health insurance and their income ends up being higher than the income on which their credit was based. i share senator menendez' concern that this is going to cause an undue problem, undue burden. this could increase premiums on people paying health insurance or reduce the benefits of their health insurance coverage, especially in the small business community, and he believes that his amendment would reverse the provision, and it does, in fact, do this, it reverses this provision if the secretary determines it increases premiums or it will reduce coverage, that is the health insurance coverage for small businesses. the 1099 repeal is all about small businesses. that's primarily why we repeal 1099, but we don't want to turn

around and hurt small businesses in the same bill, and it's a real possibility that that would happen with just straight repeal without the menendez perfecting amendments. so i urge my colleagues to join me in supporting the menendez amendment. the effective menendez amendment would be to go ahead and repeal the 1099 which virtually every member of this body wants to do, but also to make sure the consequences do not hurt small businesses who otherwise find their premiums increased or may find their coverage is diminished. so menendez very wisely anticipates that potential problem with his amendment by essentially providing that the increase would not hurt -- occur was premiums -- that is, the 1099 appeal would not occur if -- if h.h.s. secretary determines that it would increase premiums or also reduce

coverage for small businesses. so i urge my colleagues to support the menendez amendment. a senator: mr. president? the presiding officer: the senator from utah. mr. hatch: mr. president, today we will vote on the menendez amendment and then on senator johanns amendment to repeal the 1099 tax increase provision from the health spending law and the small business law. as you know, the health spending law was enacted a little over a year ago. we already here are trying to undo some of the damage this massive law has imposed on small businesses. we've heard from small business owner after small business owner that was shocked and frustrated to learn that the 1099 provision in the health spending law would require small businesses to send out a much larger number of i.s. form 1099's. this provision was counterproductive. it was a counterproductivive

assault on businesses. it was unleashed for one reason, to provide the dollars to pay for $2.6 trillion in new spending. in other words, to try and back up that spending. just to be clear, this is what this provision requires: starting on january 1, 2012, if a business pays at least $600 in total in one year to a single payee, that business must send an i.r.s. form 1099 to the i.r.s. as well as to that payee. since businesses frequently pay at least $600 in one year to all kinds of different payees, this means the health spending law has created an enormous paperwork burden on our businesses, including many small businesses. this is exactly the kind of burden that small businesses do not need to face at this time. when we are still facing unemployment at 8.8% and small businesses create 70% of new jobs in this country. the national federation of independent businesses whose membership is made up of small

businesses hit the nail on the head in its april 4, 2011 letter, about this provision. this is what they had to say -- quote -- "we are writing to urge to you support h.r. 4, the comprehensive 1099 taxpayer protection and repayment exchange subsidy overpayments abg of 2011 and to oppose the menendez amendment. passing h.r. 4 without any amendments is the best way to finally repeal the expanded form 1099 requirements included in the patient protection and affordable care act. tax paperwork and compliance are already major expenses for small businesses, and the new reporting requirements included in ppaca will substantially increase these costs. the new paperwork mandate will require businesses to track and report to the i.r.s. most business-to-business transactions above $600 in a calendar year. for many businesses this could amount to hundreds, if not thousands, of new reportable

transactions which involve sending a 1099 to both the i.r.s. and the reportable business. that's a pretty strong statement, and the message is clear. this provision will impose considerable hardship on american business. the result this have provision will be much more paperwork but much less job creation. i spoke this morning to the tax executives institute, which is one of the most prestigious institutes in our country, especially on taxes. and when i announced to them that i think we're going to get rid of this provision, i almost got a standing ovation. they went wild down there this morning. this provision will impose considerable hardship on american businesses, especially small businesses, and the result of this provision will be much more paperwork but a lot less job creation. in addition, on april 4, 2011, the united states chamber of

commerce weighed in on this provision with a similar diagnosis. this is how the chamber put it: "the 1099 reporting mandate, if not repealed, will force more than 40 million entities, including governments, nonprofits and small and large businesses, to comply with onerous data collection and i.r.s. information filing burdens on virtually all non-credit card purchases totaling $600 or more with any vendor in a tax year. at a time when they can least afford it, entities will have to institute new complex record keeping, data collection and reporting requirements to track every purchase by vendor in payment method. this provision will dramatically increase accounting costs and could expose businesss to costly and unjustified audits by the i.r.s. the chamber supports h.r. 4, which would repeal the 1099 mandate and strongly opposes the menendez amendment."

unquote. so i ask unanimous consent that the letters from both the n tp*eu b, the representative of small businesses in this country, and the chamber of commerce, be printed in the record at this point. the presiding officer: without objection. mr. hatch: thank you, mr. president. president obama and congressional democrats tried to sell the american people on their clunker of a health care law by saying that it would bring down federal health care spending. that would have been a miracle if it were true. but even the administration's own actuary at the center for medicare and medicaid services has confirmed that that claim was false and that federal spending on health care would actually increase as a result of health spending law. some estimate as much as $2,100 per policy. the cash for clunkers program was bad enough, but democrats managed to outdo themselves spending $2.6 trillion in cash for this clunker of a health care law. now this reminds me of a scene from the movie "vacation." at the beginning of that film,

clark griswold goes into a dealership to buy a new car before setting off with his family for a cross country trip to wally world. instead of getting the new car he ordered as part after trade-in, the dealer gave him a pea green family truckster as you can see in this photograph. one only had to look at the family truckster to know it was a lemon and clark told the dealer he wanted his own truck back. unfortunately, for clark, the actor in this case, his old car was crushed before he could get it back. you could imagine the consternation on chevy chase's face. you can see the family truckster and this car behind me. there it is with chevy standing on top as clark griswold.

clark's experience with the familily truckster is a metaphor for america's experience with obamacare. our nation's health care system might have needed some work, no question about that, but the vast majority of americans were satisfied with their health care. yet, democrats gave americans obamacare which, like the family truckster here, is a true jalopy, and they did their best to crush our former health care system before we could stop them. i would also add that americans like clark griswold eventually reached their wit's end. the tea party, the gubernatorial elections in virginia, the senator from massachusetts were the result of americans letting us know they were tired of letting washington recklessly spend their money and recklessly regulating and therpb not going to take -- they were not going to take it any more. to borrow from roger daltry,

americans made it clear they were not going to get fooled again. that did not stop democrats. at the time health care law was being enacted, democrats were raising taxes to make it clear they were partially paying for it. when democrats say that this health law saves money, you should ask yourself this: if the law was actually going to reduce federal spending on health care, would these massive tax increases have been necessary? in the end, obamacare was more of the same. a tax-and-spend law that vastly increased the size of an already bloated federal government. president obama and congressional democrats should not have raised taxes and cut medicare to fund the new entitlement program and then u.s.s. -- an unsustainable entitlement program. the three largest entitlement programs -- social security, medicare and medicaid -- are already headed for fiscal crisis. to create a fourth massive entitlement program when these

three entitlement programs were already going broke was fiscal insanity. that's one reason why we need to repeal the health spending bill in its entirety and start over. senator johanns amendment to repeal the 1099 provisions in the health spending law and small business law is a good first step at getting rid of the partisan health spending bill entirely. i think a lot of people, including some members of congress, have voted for the small business bill last year and were surprised to learn that congress enacted a second 1099 provision last year. this is separate and apart from the 1099 provision enacted in the partisan health spending law. this new 1099 provision was enacted as a part of the small business law last year. i voted against it. by the way, this provision is already in effect since it applies to payments made on or after january 1 of this year. this 1099 provision causes landlords that aren't even

actively engaged in the rental real estate business to send in a form 1099 to the i.r.s. it's required when they pay more than $600 in one year to a vendor for goods or services. for example, suppose a landlord spends more than $600 over the course of a year at a home improvement store. that landlord must fill out a form 1099 and send it to the i.r.s. as well as to the provider of goods or services. in addition, that landlord must track down the vendors' taxpayer identification number, which is not necessarily an easy task to do. this law creates a large and unexpected paperwork burden on these landlords. with the real estate market struggling, we should not be imposing new paperwork burdens on landlords which only hurt the real estate industry even more. i urge my colleagues to vote "yes" on senator johanns amendment. vote "no" on the menendez amendment. like i said, senator johanns'

amendment is a down payment on total repeal of the onerous health care law that over time will wreck our nation's health care system and lead to an explosion of new federal spending. so i urge my colleagues to vote "no" on senator menendez' amendment. and i want to personally pay tribute to my colleague from nebraska for his indefatiguable efforts in trying to repeal these terrible paperwork burdens that nobody's going to look at anyway that, really aren't going to make any difference and are just going to cost an arm and a leg over time. i just want to thank him for all the hard work that he's done. he deserves a great deal of credit for continuing to fight these battles, and i hope that he will clearly -- i hope that all of us on the floor will get rid of this monstrosity here today and hopefully work together to try and straighten out what really is a very bad bill in obamacare. mr. president, i reserve the balance of my time. mr. baucus: mr. president?

the presiding officer: the senator from montana. mr. baucus: mr. president, i ask how much time is remaining on each side. the presiding officer: the majority controls 19 1/2 minutes. the minority controls 8 minutes. mr. baucus: thank you. mr. president, i first want to correct the record. i stated earlier that the menendez provision, if it's triggered, that 1099 repeal won't go into effect. that is not correct. what i meant to say is if the menendez provision is triggered, the new rules in the h.r. rule won't go into effect. that is an important distinction because no matter what the result might be, the 1099 will in fact be repealed. that's the main point. i commend all senators, including senator johanns and others, who want to repeal the 1099. that's very much the view of this body. i myself want, firmly want to repeal a 1099, but i also think the provision offered by senator

menendez is an improvement upon the repeal, even though the repeal will actually go into effect. mr. president, i might just also say that statistics bandied about about health care reform. a fidelity company does an analysis of how much it costs people age 65 and older to pay for their health care. that's their cost, their premium cost as well as their insurance cost or out-of-pocket costs. fidelity company has just concluded recently in the last, i think, week or so that as a consequence of health care reform, the number of dollars that seniors will have to pay for health care is actually going to be lower. not higher, but lower than it otherwise would be on account of passage of that bill. i might say also, mr. president, that there's -- eufpt to say a

couple -- i want to say a couple of words about the budget proposal offered by the house, the ryan budget proposal. it's important for people to know what's in that budget. what's in it basically? let me tell you. that budget cuts $2.2 trillion in health care costs over ten years. $2.2 trillion in cuts to health care costs over ten years. it repeals health care reform. that's the ryan resolution. his resolution repeals health care reform. what else does it do? it dismantles medicare. it dismantles medicare as we know it. mr. president, health care reform extends the life of many by another 12 years. the ryan house republican budget proposal repeals medicare as we know it. it turns into a voucher program. basically it says this: there have been reports that it costs

about $15,000 to pay for seniors under medicare a year. there have been reports that the ryan proposal says, we're just going to give people $6,000 and give to a health insurance company. first of all, that's a big cut, $15,000 down to $6,000. second it's a health insurance company. the net effect of the ryan proposal is very simple. it transfers wealth from seniors, from children because of medicaid, and people in nursing homes, it transfers wealth from them to who? health insurance companies. the medicare proposal is a transfer of wealth from seniors to health insurance companies. mr. president, health care reform did the opposite. we extended the life of medicare. how did we do it? in part by cutting health insurance payments. so we help seniors in health care reform and we cut health

insurance companies. the ryan house republican budget proposal does the opposite. it cuts benefits to seniors by a whopping amount and takes that wealth, transfers it over to health insurance companies who will get higher premiums, get higher bonus payments, they will get dire their stock returns will go up, administrative expenses will go up. i don't think that's what we want to do. make no mistake, that is the effect of the ryan proposal. it also, i might say, reduces income taxes by about about $1.2 trillion. so the real net effect of the ryan proposal is to take money away from people and give it to health insurance companies and the wealthy. that's what the ryan proposal does. that's exactly what it does. the ryan proposal takes money,

about $5.8 trillion, roughly, over ten years, takes it away from people, especially seniors, kids in medicaid, elderly who happen to be in medicaid. big reductions further in discretionary spending, and lowers income taxes by about about $1.2 trillion, lowers them. that's how we -- he achieves budget savings of $5.8 trillion. he just cuts, cuts, cuts to the bone, and then cuts so much, he cuts about $1.2 trillion more than he has to because because $1.2 trillion is increases in income -- is reductions in income tax. i just want the republic to know what is in the ryan budget, and that's what it is. let me say it one more time,

clearly, simply. transfer money away from seniors and from kids in medicaid, elderly in medicaid over to health insurance companies who hire bonuses, hire salaries -- higher bonuses, higher salaries, stock goes up, and in addition, it transfers money away from people to pay for tax cuts for the wealthy. not tax cuts for the unwealthy, but tax cuts for the wealthy. well, how did he do that? he lowers the top rate down to 25% so the wealthy pay less taxes. he lowers the corporate down to 25% so the bigger companies pay less taxes. that's how he does it. so while we're talking about a short-term c.r. around here and we're talking about a longer term c.r. around here, we start talking about budgets, let's look closely at what's in -- actually in that ryan proposal. of course, we have to lower our

budget deficits. of course we have to significantly lower our budget deficits, but of course we have to do it fairly so all americans are part of the solution, all americans are part of the solution, so that health insurance companies are also part of the solution, so the most wealthy are also part of the solution. all americans have to be part of the solution. the ryan budget does not do that. it says only seniors -- we get the budget deficit reduced on the backs of seniors, we get it on the backs of people otherwise receive medical care under medicaid and some other things, but also we lowered taxes for the -- we shipped income to the most wealthy by lowering their taxes. now, mr. president, i just hope that when we're voting on the menendez amendment, which is the important thing to do, we also in the background understand what's going on on the other

body over there. they may bring it up, try to pass it this week. they may try to pass it on the floor next week, i don't know, but we should recognize it for what it is and come up with a budget -- a deficit reduction proposal that really is fair. it's fair to all americans, fair to all americans. not on the backs of seniors for the benefit of health insurance companies and not off the backs of average americans that benefit the most wealthy by lowering their income taxes by by $1.2 trillion over ten years. that's not fair. i yield the floor. mr. hatch: mr. president? the presiding officer: the senator from utah. mr. hatch: we're headed toward toward $20 trillion in spending. the democrats' program cuts .5%, which is almost nothing. this is their program, a blank sheet of paper. that's what it is. at least ryan -- the budget committee chairman over in the house is trying to do something

worthwhile. by the way, just so everybody knows, the rich aren't going to be treated tremendously respectfully in this matter. they are going to lose on the top level on entitlement programs, so there is a cutback for those who reach a certain level of income. mr. -- and so this isn't as simple as it sounds nor is it a desire to take anything away from senior citizens. it's trying to get our country's budget under control, and it's out of control. with that, mr. president, i want to yield up to five minutes to the distinguished senator from maine. mr. baucus: would the senator yield for a request? mr. hatch: sure. the presiding officer: the senator from montana. mr. baucus: i have eight unanimous consents for committees to meet during today's session. they have the approval of the majority and minority leaders. ski that these consents be agreed to and be be printed in the record. the presiding officer: without objection.

the senator from maine. ms. snowe: thank you, mr. president. i rise today in support of h.r. 4 to repeal this onerous mandate on small businesses throughout this country. the failure to repeal this onerous mandate of the 1099 requirement will have a profound impact on millions of businesses across this country at a time in which the already stressed job market as employers have to grapple with the enormity of this cost, not to mention the compliance with this regulation. i certainly want to commend the author of this legislation, the senator from nebraska, senator johanns, for his tenacity, his perseverance, his relentlessness in bringing this to the forefront, not only of the senate but the congress and the country, and hopefully today we can join with our counterparts in the u.s. house of representatives in an impressive bipartisan vote because we really do need to bring this to a conclusion. i also appreciate the fact that the senator from nebraska

included in this repeal also the provision that i recommended which was to repeal the provision as the mandate would be extended to rental property owners. this is a requirement that was included in the small business jobs relief act that became law last fall, inexplicably given the fact that the 1099 quagmire was already well known to everyone, but yet it was included in that legislation that became law. so those who are rental property owners will have to comply with this mandate as well. the big difference is that this requirement takes effect in january of this year, so unsuspecting owners will already be subject to the burden of reporting to the internal revenue service i.r.s. -- internal revenue service any businesses for services that exceed $600 vendor, just like all other requirements of the law which will begin in 2012 for

all small business owners. as we all know, this new mandate on small businesses was imposed under the health reform law and yet had nothing to do with reforming the health insurance industry. it had everything to do with raising revenues and placing an inordinate burden on small businesses. the rental real estate was added to this paperwork morass, and what's disconcerting is the fact that it affects directly those states that depend on tourism such as my state of maine with respect to rental property. so i think that it is going to be very important to make sure that people understand that this requirement will be repealed as part of this legislation. it will -- failure to repeal this mandate will raise the compliance costs for small businesses astronomically. already as estimated by the nfib, the major voice for small businesses in this country, they have estimated that small business compliance costs with

respect to tax compliance alone is $74 an hour. tax compliance is the most expensive form of paperwork, so the burden on small businesses will be strenuous and inordinate. it is already disproportionate. their costs are 67% higher than larger firms. so there is no question given the ubiquitous nature of this requirement that small businesses all across this country will come under the weight of these very stringent regulations with having to submit 1099 forms. in fact, i was talking to an individual the other day who heads up an organization which has 1,650 members, and what did he say? he said every one of those members will have to file anywheres from 200-600 forms every day. that's 200-600 forms on a daily basis. they didn't want to talk about taxes, they didn't want to talk about anything else. they wanted to talk about whether or not we were going to repeal the 1099 requirement.

that's why there is so much support for this repeal. mr. president, it's why it's so important during these difficult economic times that we have to avoid imposing any tough regulations on our small business owners. the other point to be made here is this 1099 requirement is vastly different from what is familiar to most americans. 1099 forms generally come from their financial institutions to report the interest that they have earned on their savings accounts or to report the interest that they pay on their mortgage to their lenders. now that requirement is specific to make sure that they report directly their tax liability on the income earned in that specific tax year. now we're revert to go a very different form by requiring businesses to report in the aggregate all of their expenditures of goods and services to any vendor. that's a very different requirement. my concern is, mr. president, one that has not been widely

discussed, but the fact is by doing so, by making this conversion how we use 1099 forms is essentially putting in place an infrastructure, a system for value-added tax by reporting -- by requiring businesses to report all of this information. so you could essentially have a system in place where if you could have a functioning value-added tax by taking the next step based on the information that is already required to be submitted by this requirement. it is urgent that we repeal this mandate, it's important to send that message, and it's important to repeal this mandate in its entirety. i yield the floor, mr. president. the presiding officer: who yields time? mr. hatch: how much time remains on both sides? the presiding officer: the senator from utah has a minute and 20 seconds. the majority has 11 minutes.

mr. hatch: i reserve the balance of my time. a senator: mr. president? the presiding officer: the senator from new jersey. mr. menendez: mr. president, i know that we often read that democrats and republicans can't agree. well, here's a news flash. we agree on repealing 1099, and i have listened to my three distinguished colleagues present a lot of their time talking about repeal of 1099, and we absolutely agree. i myself have voted six times to do that. so that's not an issue. what is an issue -- and my distinguished colleague from nebraska who i have worked with before in passing some important legislation, i have a great deal of respect for him. he talked about a victory for small business. i agree. but i want a total for small business, and a total victory for small business is not repealing 1099 and then giving them a bigger tax bill to their employees or raising the costs of insurance for that small business. a real victory is an opportunity

to make sure we repeal 1099. my amendment has 1099 repeal going forward. but then there is a study that says, you know, if small businesses are going to face higher costs or their employees are going to face a $10,000 tax bill, well, then that part of it shouldn't proceed. now, if i'm wrong, nothing will happen. the study will come. they'll say no, small business isn't going to have an increase. no, taxpayers aren't going to get a surprise tax bill. the repeal will have already gone through, and there is no foul, no harm. but if i'm right, then voting against my voament is voting -- my amendment is voting for a tax bill for middle-class families, voting to increase insurance on small businesses. now, the issue about going quickly to the president, first of all, this is a priority, so if we pass this, this is not as has been suggested an alternative. it's just a single amendment to