billion solution? >> we support a robust bill. we think 18 months since the time to do that. the current bill expires at the end of september. there's no way they can pass a comprehensive bill. we want a comprehensive bill and we want to find a way to pay for these things. we are not against building roads and bridges and all of the things that we do at the dot -- trains, planes, and automobiles. that is what we are interested in, that and safety. but it takes time to do that and congress is wrapped up in so many issues. that is the reason that the senate went along with that. in the end, the senate passed that. the house pass something that as you said as a stop-gap measure and now the senate has done that. we have a stopgap but we are pushing for a longer extension

and the money to pay for that. >> before we let you go, you had a meeting saturday morning with your colleagues in the cabinet. can you give us some color as to what came out of that session? >> i think a great opportunity -- we have all been so busy in the first six months of this administration. the implementation of stimulus. all of the legislative activity around climate change. the activity around health care. what we have been doing at dot is a great opportunity for the cabinet to bond with the president. to form the kind of team that we have all been really doing. but without the relationship building. if anything came out of that, it is the kind of relationship that really had a chance to form to get to know one another.

to really understand what the president's priorities are. friday night they spent a lot of time with us. there was a lot of good interaction. we know where the president wants to take his agenda. i think -- i feel privileged to have a front row seat. it is a great privilege to serve with the president and his entire team. some of the smartest people and some of the hardest-working people i have ever met in my 30 years of public service. people who are making great sacrifice to serve america. i want americans to know that. there are people in this cabinet making huge sacrifices because they believe in america, the president, the agenda, and we are a team. >>, six months into it -- ray

lahood, six months into his job with the transportation department. let me begin with duke. the editorial saying -- >> this is pretty novel. the only other attempt was in germany were there was a short- term spike in car sales but then there was a drop next quarter. all it did was move people up who were going to buy cars anyways as opposed to stimulating new demand. they are selling a whole lot of cars, but i think it remains whether or not this is doing anything more than taking car purchases from later in the year. >> ken thomas, what came out of today's conversation? >> i think it is clear that they have leverage and they can tell

the congress if they do not approve the additional $2 billion they will have to suspend a popular program. it is playing in peoria and a lot of places and the congress will be pressured. >> it should not be taken for granted that the senate will act -- as said earlier -- the senate is a deliberative body. there are republican fiscal conservatives who are unhappy with this and even some of the energy folks to see that because they see that as stepping on their turf. judge sonia sotomayor's nomination is this week. there is not time to get this done. >> a new question about where this is heading. what did you hear? >> i think the democrats can make the argument that this was timely and targeted. this could actually -- this could be helpful.

they can make the case that another $2 billion will continue to pump -- to prime the pump. >> a fair observation. they like this program. they can point to this. the stimulus has been criticized but this is working. look at the demand. it led to chaos but chaos where people were buying cars. >> ken thomas, washington correspondent for the associated press. our thanks to ray lahood for joining us on the sunday program. have a good day. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> next, amendments to the health care bill, and then a hearing on ways to reduce stress among states service members and then a dialogue between u.s. and china.

>> george signed the declaration of independence and was murdered. chadwick on "i am murdered." tonight at 8:00 p.m. eastern and pacific on c-span. >> gordon brown before the 30 members of the house of commons liaison committee answering questions on the british economy, a banking crisis, and foreign affairs. >> on thursday and friday, members of the commerce committee debated amendments to the health care bill and now a portion of friday's debate and vote. this last 2.5 hours. in two at colloquy to discuss an agreement reached last thursday between you, speaker posey, chairman rendell, chairman miller, representative becerra, crowley, short, kind, insley, me and

others. the agreement is to include language in h.r. 3200 as it moves to the house floor to address geographic disparities in medicare reimbursements and a shift toward a medicare system based on high-value care. >> the gentleman will yield. i was pleased that we were able to address many of your concerns with the medicare payment structure. >> mr. inslee. >> i appreciate that, mr. chairman, and the agreement we have come to, and this is exhibit a and i ask unanimous consent to enter it in the record. with speaker posey's support should take great strides to address the geographic and equity in medicare and moved towards a payment structure that reimburses or high quality, low cost with clear. specifically, the language will mandate to studies by the institute of medicine. and i will discuss it -- discuss the first which relates to geographic and anna care and

mr. brady will discuss the second. which was our medicare payment structure towards rewarding high-value care. with respect to geographic and equity, the first study will address the accuracy and efficacy of the factors that make up the various geographic adjusters in medicare. upon completion of the study, the secretary will make the recommended adjustments and provide appropriate increases or reimbursements based on the adjustments from a medicare proven fun. after two years and hold harmless provision expires and a payment for all new adjustments will then be provided in a budget neutral way. mr. chairman, i ask unanimous consent to put in the record exhibit a and incorporate in that agreement. >> without objection that will be the order. >> the second study will assess the best way to shift our medicare payment structures to one that reimburses for high-value care. according to our agreement, the study will be completed within two years in the recommendation submitted to the secretary. the secretary will then have 45 days to submit an application

plan to congress and congress will be faced with the option of a joint resolution of disapproval subject to presidential veto by the end of february 2012. if congress does not pass the joint resolution of by the end of victory 2012, then implementation plan directly reflective of iowans recommendation will be implemented by the secretary. i thank the chairman for your hard work to address our concerns in this area, and for the inclusion of our agreed upon la which in the house bill as it proceeds to the floor. >> will the gentleman yield to me? i assure the gentleman that it is the leadership intention to add the agreed upon language as you have both described, you and mr. ainsley, to h.r. 3200 before the bill reaches the house floor. this agreement will provide us with a fair, unbiased assessment of how to best proceed towards a medicare reimbursement structure

that pays for high-value care and addresses some of the issues of geographic and in equity in medicare. i thank both of you for your efforts, and it is leadership intention to make sure this language is added in the house bill. >> thank you, mr. chairman. >> the chair recognizes mr. ross for purposes of this eminent. >> i have an amendment at the desk. >> mr. chairman, i reserve point of order. >> the clerk will report the amendment and mr. deal reserves a point of order. >> amendment to the amendment in the nature of a substitute aged. >> without objection the amendment will be considered as read. the gentleman from arkansas is recognized for five minutes. >> mr. chairman, i am pleased to offer this amendment which reflects concern some of my college and had when we first began this markup. and it's a product and a result

of about two weeks of intense negotiations where there was a lot of give and take. specifically, this amendment would make sure that small bunesses remain open while ensuring affordable health insurance to their employees as well as to those small business owners. ensures that the public option competes with the other qualified health benefit plans on a level playing field and clerk buys positions will make it their choice to opt out or into the public plan. it make sure that providers who accept the public option are paid at negotiated rates and are not tied to any other governmental plan. it clarifies that no one will be forced to enroll in the public option and that all who enroll in the health insurance exchange are free to choose the public option or a private health insurance plan of their choice. it ensures that agents and brokers are allowed to sell

health insurance plans are enumerations that states have the option to create their own cooperative type health insurance plan to provide consumers even more choices. clarifies that existing state insurance exchanges are allowed to continue operating. requires states to maintain a share of the cost in ensuring their medicaid populations while ensuring the federal decay dollars are being used in a quality and efficient way. implement innovative delivery reforms to benefit cost curves include the creation of a new, innovative payment center to speed up comprehensive testing of new payment models. ensures that all americans are provided with clear, straightforward guidelines regarding their options for advanced directives. find additional savings within our current public programs and ensures we get more value for every health care dollar we spend. mr. chairman, we have an historic opportunity to transfer our health care system into one that meets the needs of all americans. we cannot pass up this moment without fundamentally --

>> the committee is not in order to jump from arkansas deserves to be heard. >> mr. barton is correct. the committee is not in order. mr. ross, continue. >> we cannot pass up this moment without fundamentally changing the incentives in our system to reward high quality efficient health care. i was pleased that we were able to come to an agreement. i appreciate my colleagues work on this amendment and look forward to working with the chairman and others on ensuring these and other provisions are included as the bill makes its way to the floor. mr. chairman, i would ask for a yes vote on this little old noncontroversial amendment i have your. >> the gentleman >> does the gentleman yield -- the gentleman still has two minutes -- any other member?

the gentleman from ohio. >> thank you. i first want to thank my friend from arkansas along with my colleagues baron jill, john barrow, for working so diligently over the last couple of weeks in a sincere effort to make this bill better. we believe that is what this amendment does. it has done a lot of things. i do not have the time to detail all of them but i want to focus my remarks on a couple of remarks that will make this bill a lot better. one of those areas is with respect to the reimbursement of the public plan. the original bill tied that reimbursement to medicare. while that may sound good, in rural america that will not work. our hospitals are very small, generally. anywhere from 65% to

75% of everybody that walks in the front door of these hospitals is either on the kate or medicare. they are losing money on those patients.gn)n h@ @ @ this is insuring or almost ensuring that many of those hospitals will go out of business. not only will that be disastrous to the quality of care in rural america, our primary interface, it will be a financial and economic disaster as well. these hospitals employ more than any other organization and the counties that they are located and they are economic engines that they depend upon. this change in the legislation

as incorporated in the amendment will have to -- will help these small hospitals survive. >> the gentleman's time is expired. mr. barton, recognized for five minutes. >> i want to make sure they have the right amendment. is the amendment being considered the amendment that was noticed at 3:34? >> i believe so. the clerk to make sure. >> yes. >> then, mr. chairman, i make a point of order. i want to insist on the point of order that the amendment is not germane. >> the gentleman has reserved a point of order. >> may i speak on the point of order? >> the gentleman is recognized. >> mr. chairman, we have been advised by the office of the parliamentarian that the health care of the members of congress is and i quote, not within the jurisdiction of the committee on

commerce. indigo. section 230 of this amendment on pageboy nine is a sense of the committee that nevers of congress should have the option to enroll in a public health insurance option. the parliamentarian office has been very consistent, and the chairman has been very consistent in the application of the parliamentarian's advice and has advised us on numerous locations several times during this markup that the germane here it is not affected by merely mentioning health care coverage of members of congress. accordingly, i make a point of order that the amendment before us right now is not germane. >> i believe the gentleman is correct, and i would ask the gentleman from arkansas to strike or to remove that, unanimous consent. >> i would object to unanimous consent request. >> can we be heard point of order? on the point of order. >> yes.

[inaudible] >> page 29. section 230, since the committee regarding. >> mr. chairman, isn't it true that something that is not binding on the law such as a whereas clause or a sense of congress, is not what governed the parliamentary trigger? it's got to be the part that changes the law. >> the house parliamentarian is available right now, if the gentleman from arkansas wishes to withdraw the amendment and the chair wishes to check with the house parliamentarian, i am absolutely certain that they will stay as i have stated. the amendment as it is currently before this committee is not germane. >> i don't disagree with the gentleman, but i would just like if we could just pause for one minute. >> mr. chairman?

>> the gentleman from arkansas has the unanimous consent request. >> i object. >> mr. chairman, at the urging of the ranking member of this committee, that the section be removed that states it is the sense of the committee on energy and commerce of the u.s. house of representative, that nevers of congress should have the option to enroll in the public health insurance option is clearly what that language in the amendment, that's why it's included in the at this time. but at the urging of the ranking members, members of congress not be included, i would ask unanimous consent to strike page 29, section 230, which is simply -- we will make his real easy. everyone has a copy of the amendment. all you have to do is go to the last page and do that. and do that. and that's what we would ask to be done, mr. chairman. >> believe it or not, we are talking to reading, texas. i can still be. i object to unanimous consent request.

we have laid the germane game this entire market. this is probably the most important amendment. it's not my fault that it was drafted to be nongermane, but it is not germane so i'm going to insist on the point of order and. >> will the gentleman yield to me? >> i will be happy to yield to the chairman. >> the last time there was a germane this issue, the gentleman came back after you realized that we were following the parliamentary -- parliamentarian's instructions correctly, and we agree to unanimous consent request to strike the part that was not germane. i would hope the gentleman would get the same courtesy to -- >> in almost any other case i would, but not in this case with this bill being as big as it is and is amendment being as important as it is. i simply have to insist on the point of order and that the rules are the rules.

[inaudible conversations] [inaudible conversations] >> the gentleman from arkansas withdraws his amendment. the gentleman will withdraw his amendment. >> mr. chairman, if everyone wants to be here another three or four hours we will start again. we will file it again. >> mr. koh, do you have an amendment ready to go?

>> i would like to call up the following amendments in block. doyle two on autism, eshoo 1001. schakowsky 7001. sorbet and 5001. green 9001, lacks and division see, funding 002. waxman division c. funding 004. gordon 13. . .

ok. >> mr. gollel, have you completed the presentation? the gentleman from pennsylvania requested that he be mentioned and considered. without objection, the reading of those amendments will be dispensed with. as i understand that, they are non-controversial. therefore, let's proceed to a

vote. >> the list that we have agreed to -- i assume -- that we have no objection and we support that. >> let's proceed to a vote. all those in favor of a agreement, say aye. the ayes have it. the amendment is agreed to. >> i think there is a barton transparency amendment. n amendment at the desk? >> i do >> to you have an amendment at the desk? >> i do, sir. >> he reserves a point of order just in case. >> mr. chairman, i reserved a point of order. >> i think that is fair. >> the clerk will report the

amendment. >> the substitute by mr. barton and mr. stupac at the end of division c, the title -- >> the amendment will be considered as read. >> i thank the gentle man. i want to thank them for co- sponsoring this amendment. the committee is not in order. >> the gentleman is correct. the committee will please come to order. the gentlemen in taxes is entitled to being heard -- in texas is entitled to being heard. >> what kind of health package should we adopt? we should all be united in that we need more transparency in the health field. this amendment is a strong transparency amendment and it would establish the health-care

information transparency office in the department of health and human services. that commission would be composed of five commissioners appointed by the president with consent of the senate. this commission would have the authority to get the information on health care pricing, health care quality, health care outcomes, and make it available to the health care user community and open -- in an open and transparent fashion. if we have more transparency in the quality index is, in the indexes of the outcomes and the pricing and all of these different areas, obviously, with regards to which kind of health care plan each member this committee chooses to support, more transparency and accountability is a good thing. i have worked very hard on this amendment with the number of

people, mr. green among others on the majority side. i would hope that the committee would adopt that. i would have -- i would be happy to yield. >> quickly, i think you explained as well. we want transparency which will help patients and medical providers provide the best information available. this is a critically important -- especially as we deal with the public option -- the best way to make decisions for their own health care. they are given information said they can make informed decisions on cost and quality. myself and others have transparency amendments but this one is probably the most comprehensive. i am proud to co-sponsor that with mr. barton. >> yield to mr. green. >> thank you.

i will get my own time, but we have tried to work this out. this is not an amendment i can support. i will let you keep your time. i just want to make sure this is an amendment that i can support. we have an alternative. >> was told that you did support this. >> the gentleman yield back his time. do you want to be recognized on this amendment? >> of want to be recognized in opposition. i have great respect for my fellow texan, joe barton, and i am dismayed that this discussion was halted on the amendment and we were unable to reach an amendment. the grain amendment that we have been working on -- i have been working with burgess. i will have an amendment shortly if this fails.

we want to provide reliable health care information to make consumers make decisions. this would create a new federal agency. it's a penis powers to demand information from doctors and hospitals -- it subpoena powers. the commission would also have mitigating powers. many of the duties outlined in this amendment are duties that are already being performed. . they provide consumer pricing information. 34 states require hospitals. an additional seven states have voluntary efforts. our effort will be up shortly.

it also requires insurers to participate. it provides information. the real test of pricing information is what is more helpful to consumers. those consumers have health insurers. they want to know how much insurance they have to pay. they need real time information. whether it be the floor online explanation of benefits. . vote on the barton amendment. >> will the gentleman yield to make price i just want to join you and in urging that we look for your alternative rather than this one. the barton amendment was offered and withdrew, with john when we first began in the markup on h.r. 3200 and our staffs of work to bridge the differences over the last week in half and unfortunately it seems a

compromise could not be reached. i appreciate mr. barton's integrity in saying firm with what he believes to be the best way to get information to consumers health care but i respectfully disagree with the outcome. i think we have a better alternative and their alternative and one that will not draw some of the opposition to the bill that mr. barton amendment would do. so i also would urge the eminent. eminent. >> would gentleman be glad to yield to my friend from north texas? >> what is the primary objection to the bartons tupac amendment as you now? >> the creation of of of the new federal commission and actually the subpoena powers is outside of our current hhs secretary and also there's a lot of staging samples of what can be done on

transparency, that this would almost reinvent the wheel compared to what we have some ministates and i want to build on what that does he mac does the gentleman from texas and california object to the collection and of pricing information? >> no, that's not the issue. this creates, is interesting and arguing against reading hypocrisy, and democrat and republican but you created this transparency office with literally securities and exchange subpoena power. i think we will generate a lot more opposition to the legislation if your amendment is adopted. >> but is your opposition and chairman waksman's opposition just to the organizational structure? it is not to the types of information? >> with the gentleman yield to a? >> if we are fighting -- >> i'll yield to the chairman. >> we have had discussions at the staff level and argued it is too broad, for example, it gives

him much authority to collect data. does not protect the privacy, but individuals, and shares that data. with researchers. it would allow the government to collect a share with others all claims data for private insurers. it increases the costs of health care as providers learn the reimbursement rates of other providers. this is a phenomenon that the cbo and others discuss so there are a number of concerns that have about it. we tried to reach an agreement to narrow your amendments and we have not been able to do so. >> i am not -- >> recap supported. >> the time has expired when. >> let's proceed to a vote. in connection i have one minute to wrap up? >> without objection iraq i am trying to, this is our staffs into such a wonderful job and they do in all honesty brambly

95 percent of the real work. the listening to the objections that have just been at some point in time we could find a compromise on structure. i think in on privacy and nobody is a stronger privacy advocates then mr. markey and myself and. when i was so the objection was that there was an objection to plighting pricing information and i can't agree to compromise the ability to get pricing if you have to have pricing information to let the consumer in the marketplace know how to make their program health care decisions to met with the gentleman yield? >> i think maybe w@@@@@@@ @ã 8h

by will have the amendment right after this and i hope the chairman will recognize it. >> we were going to proceed to the vote. would you like an additional one minute? >> i just want to know that, apparently, i know we have worked hard on this because this is an issue i have been talking about in this committee for years. here we are with the last opportunity in my opinion to have a transparency in the inserted into this bill and i'm not so sure we're not throwing it out the window with this amendment being rejected, and i have not heard any detailed explanation as to why we are rejecting this. >> mr. green will have one should this one be defeated. >> ok. >> all those in favor?

, opposed to no. no, to reckon i have a show of hands on the request to mccaul those in favor of the printing a man and, please, raise your hand in the clerk will count the one hand person. there's one over here too. i want all that has counted. all those opposed to the amendment please raise your hand.

i hope the clerk noticed everybody. the clerk will announce the tally. >> mr. chairman, there were 18 ayes and 20 nos. >> the amendment is not agreed to appear now mr. ross, uc recognition for an amendment? >> mr. chairman, i have an amendment at the desk and the clerk will report a man and. >> we want to reserve a point of order, mr. chairman, the gentleman from texas reserves a point of order to recommend to the nature of his substitute of h.r. 3200. >> without objection will be considered as read and gentleman recognized to explain his amendment. >> mr. chairman, this is a the same amendment that i have described earlier, less one page. and i might add to you that i'm very disappointed that the

minority would not want to require someone members of congress to have the same option as the american people will. there's been a lot of rhetoric of the public health care option in the this is an opportunity to set the record straight. the public health care option is just that, an option. is consumers more choices, and does not require a single american citizen to select this option and lessee or she chooses to. and all we were attempting to do was give members of congress the same option that every american citizen will have that qualifies for the public option plan and that is the opportunity to opt into it if they so desire and the same opportunity that will be afforded to many american citizens so it is with sadness that members of congress will not have this option at the insistence of the minority. nobody other than that everything is in this amendment

that was in imminent to eminence ago and i would ask for once again for a yes vote on this little noncontroversial amendments. >> will the gentleman yield? >> but i think the gentleman for yielding, i've been asked to speak about the language that addresses the directives living wills and this bill. we all believe it is inappropriate way for individuals to make choices for themselves. from many times loved ones are left to guess as to whether relatives would have wanted, advance directives are one way to ensure everyone's personal issues are carried out by medical personnel this provision would direct all qualified health benefit plans to provide information on advance directives to all individuals seeking involvement in their plan. a person can then choose whether or not to establish a directive for themselves so they have a choice. it's not forced upon them. the provision also clearly states we're not promoting suicide, assisted suicide or the

intentional he saying of death. members of the committee when this is always a very difficult thing to talk about. the end of our lives. and i just about every say that i know i think all the states have living will legislation. this is one where a person can before he nears death consign them for one of the insurance policies or the government plan and either say yes or no to the living will or advance directive. joyce is here, these are all difficult decisions but this is a very important components, the agreement we have worked out and i think one everybody for working very hard on this. and i'll yell back to the gentleman. >> with mr. ross,.

>> mr. chairman, and i yield to the gentleman from ohio, mr. space. >> i think my friend from arkansas this eminence as a lot of things. if held some bringing costs down who committed provides assurances that many of the same programs that this bill applies to medicare, this pilot pgrams that are designed to save billions of dollars over the course of the lifetime of this bill. those same programs are now being applied to medicated. i think most of us in this room recognize that medicated has been improperly managed, for many years, and it has served as a sieve as my friend from georgia use analogies earlier. this bill, one of the things it does is directs a study said that we can determine once and for all whether the formula that determines with federal contribution under the federal medicaid assistance program is fair and equitable to all

states. now there are a lot of questions as to whether that formula one is fair two all -- or fair to california. this bill or this amendment contains specific language designed to identify the problems associated with the current formula and fix them. this bill is designed to official the cost curve, something that all of us recognize is a major problem. one of the compelling reasons why we need to fix health care, not only is it right in terms of providing a better standard of care and quality of life for the people who represent, our country can no longer sustain this cost curve. this amendment is designed to help control that cost curve. i urge all of my colleagues to look at this closely and vote yes on this amendment. i yield back. >> mr. chairman, i yield back the balance of my time to read the gentleman's time has expired. >> i have several questions for council and the chairman, the

first is this appears to be the same amendment they just of the last tejon. has this been at the desk without the last page for two hours? >> i don't believe so. >> then it wouldn't comply with your role? >> but my second question is if we get beyond that the eminent as is clearly drafted is replete with brackets and which usually a bracket is a work in process and is to be inserted later in this case you have brackets and then you do have a text that appears to comply with the bracket and to get to page 28 where you have a bracket been the, congressional option but then there is nothing that who

applies to that. i mean, how can we have -- and a stand that this has been worked on the virtually for several days, but it is about the going for one of the most important bills that this congress is going to consider. i would hope that we could please get in amendment at the desk and number one complies with the chairman's request that all amendments be in place for two hours and number two, is drafting a way that complies with an of drafting requirements for amendments to be considered by this committee. so i would ask the council about these various brackets in this amendment. >> mr. arkin, the bracket and language simply refers to title and not go into the final legislation. >> why are they in the eminent than? why you have a bracket that refers to a title that is not in the bill? q1 vader just for descriptive purposes so it can track our way to the amendment that would not

go into the final legislation. >> why did the brackets in those cases actually refer to what is in the bill but the last practice does@@@@@@@@oá@ @ @ @ >> that language would not be reflected in the final bill. >> you have legislative council behind you. >> this is the most important amendment in this markup. it is not compliant with the two-hour requirement and it is not drafted in a way every other amendment has been drafted. if we want to take a recess, get it right, bring it forth, have a debate on the substance, let's do it. >> legislative counsel? >> because of the length and complexity and number of elements in this, it was felt it would be helpful to members to

have a distinction among the deed -- among the different components of this amendment. therefore, we had decided as a matter of helping the numbers to identify the specific elements -- >> how does it help numbers to have a bracket for something not currently in the amendment? >> for the last provision, it would have been helpful if there were not a point of order raised. >> why wasn't the amendment redrafted properly, put at the desk in the proper time, considered with the proper rules the chairman has requested this marked the conducted under? command will the gentleman yield to make price legislative council drabs the bills that we consider. this is the draft of the bill received a legislative council. as far as the two hours are concerned, that has been a rule

that the share has use for purposes of recognition. some members would have an amendment available so they know what is coming up. this amendment has been available for an excess of two hours, members have known when the eminence was going to be. a minor change has been made to the amendment because of a then on germane section. we have allowed the other amendments that have been available for two hours or more to have some minor changes made to them. and i see no reason why and i shouldn't recognize as i have to make you are violating your own will mr. chairman. >> my roles are for my recognition of members to make sure that all of our colleagues have the benefit of the proposal is going to be. and i can see that anyone could argue they did not know that this amendment was going to be considered. >> i think it is disingenuous for you to put a relent to place, i didn't put the ruling

to place. the history of this committee has been the members to offer amendments at any time. i think there is some value in your to our role but if you're going to have issued be effective for every amendment and every member regardless of their majority or minority status. i understand the frustration of and how difficult this process has been, i respect what the authors of this amendment are attempting to do. i commend them for aids, but on something this important i think it is fair for the minority to insist on proper order. if you choose to overlook that you're overruling your own order that you have insisted upon the aphis markup. >> i disagree with the gentleman, the amendment is before us, does any member seek recognition to speak in opposition to the imminent collapse. >> if not. >> i will take some time in. >> of kay. >> in opposition to the eminence.

the amendment and i will ask council, the amendment does not do anything to impact the public plan, is that right? >> that is not correct. the eminent impacts of the public plan and how it pays providers and changes in the underlying bill, changes that so into she's providers the seven using medicare rates. >> end is that similar to the imminent the committee rejected yesterday that would have done the same thing? >> there was an amendment yesterday that you cannot use the medicare rates as negotiated until you have to negotiate independently they rejected, is that similar? >> i believe theress is similar. >> and that is in. a way that requires the public plan to negotiate its rates totally separate from medicare? >> the amendment provides that it negotiates a race with an

upper ceiling of the average payment rates of health plans in the community and lower ceiling of the average of medicare rates? with the amendment provides. >> was the last statement? >> the amendment provides the negotiated rates within the upper ceiling of the average of the private sector payment rates in that area and a lower band of the average medicare rates in the community can and does this amendment which i haven't had time to look at until we have handed to us, does it deal with any penalties on employers, is that anything like that in this amendment if you don't provide insurance, are there penalties on employers here? is that going to --? not in this amendment. >> no search mack i think my colleagues in time on this, mr. deal. >> on the same issue, as i read the negotiation of rates, imbibe -- the minimum would be the

average medicare reimbursement rate, is that correct? >> yes search. >> so if they negotiated the minimum then that would be when the original underlying bill called for in the first place. >> of the secretary ended up in that place that would end up at the lower level yes. >> so that is -- the negotiation prize for that at the lower bound. she can go up to the negotiating rates and the average of the prime rates in that community. >> but there is no assurance that the secretary wouldn't just take a lower rate and say that is where this public option plan would reimburse that, nothing to prevent that? >> there is no assurance as to try to do that in the question would be whether providers would accept that rate can i there is no assurance should not either

one team and mr. winfield. >> one thank you very much. this amendment is i think particularly important because of over the past few weeks the american people have been totally focus on the changes that are going to be advocated by the blue dog in the u.s. congress. and i think everyone has been asking what was the agreement made between the leaders of the democratic party and the blue dog. and in this amendment i think all of the changes are the agreement must be set out in this agreement. ..

>> i think the american people were really looking forward to this amendment and were expecting some major >> i would just say >> i would just say i know this has been there for two hours or so, we've not had an opportunity to look at it thoroughly, but i'm just expressing my personal view. we have great respect forhe blue dogs, we have great respect

for every member, but i think the american people were looking for more and a significant change in this legislation than what this amendment represents. >> without objection, i'd like to give the gentleman from missouri an additional minute. >> i'd like to give time to mr. rogers, and if we have time, mr. gingrey. we'll see. >> thank you, mr. chairman. i thought my friends in the blue dogs had a great opportunity to turn this thing back into something the american people could embrace. i think it is an important amendment for what's not in it. there are some good things in here, but there still is a federally government mandated exchange. 11 million medicare advantage senior citizens are going to lose their coverage, 8 million people who have hsas are going to lose their coverage. 48 boards, commissions and programs new in this bill. it is confusing, and i have to

say, very, very dispinting. matter of fact, the only thing i think happened here, m i will yield back to the chairman. i wish you would have hung in there, sir, i think you could have made a huge difference to the american people. >> the time has expired will now proceed to a vote. all those in favor? opposed? >> a roll-call vote. the clerk will call the roll. [roll-call]

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[roll call] >> have all members responded to the call of the roll? any member wish to change his or her vote? [inaudible conversations] >> clerk will tally the vote. clerk ready to announce the vote? >> yes, sir. mr. chairman, on that vote there were 33 ayes and 26 noes. >> 33 ayes, 26nos, the amendment's agreed to. mr. shimkus, you have an amendment at the desk?

>> i do, mr. chairman. thank you. it is elr-017001. it's the only shimkus one that's filed. it is religious nondiscrimination amendment. >> without -- did the clerk report the amendment? >> not yet. not yet, mr. chairman. i'm ready. it's an amendment offered by mr. shimkus of illinois. >> without objection, the amendment will be considered as read, the gentleman from illinois is recognized for 5 minutes. >> thank you, mr. chairman, and i'll be real quick. this is to, hopefully, insure that there's nondiscrimination in any health insurance exchange against patients forerer lishes -- religious reasons who use spiritual care. there should be no additional cost to the bill, and it's already provisions already found in medicare and medicaid.

several federal employee health benefit option plans. i know there's other members that would like to speak on the bill, and i'd like to yield my time to them. first, i'd like to go to my colleague from louisiana. >> thank you, mr. shimkus. thank you, mr. chairman. i just want to support, say that i support this bipartisan amendment and encourage my colleagues to do so as well. i think it's important to clarify there's no discrimination in the exchange against patients who choose to use spiritual care. it's my understanding that something comparable was included in the senate health bill as well, and i yield back the balance of my time. >> now i'd like to yield to mr. blunt from missouri. >> i thank the gentleman from bringing the amendment. he and i have talked about it. i thank him for offering it. mr. chairman, this is a topic that you and i have talked about. it affects a number of religious groups, particularly in our state. there's a significant element of the christian science view of health care, and this amendment,

we think, would take care of them and others and is patterned after amendments that are part of current health care plans as well as current, current benefit plans, and i'm pleased to have the amendment offered. i hope it's approved, and i thank my friend from illinois for offering the amendment. >> thank you. and i'd now like to yield to the chairman emeritus, mr. dingell. >> i thank my friend for yielding to me. i am happy to support this amendment and commend him for offering it. the amendment assures americans who for reasons of religious beliefs rely on spiritual care for their health care. and to assure that they will not be excluded from universal access to health care of their choice. this legislation does not create a new precedent. it is, it affords coverage for spiritual care and such is included in medicare and medicaid as well as tricare, the federal employee health benefit

plans and state employee plans across the country. it is also a medical care deduction under section 213d of the internal revenue code. i can remember my dad talking about this when he was on ways and means committee, and it was a regularly-accepted exception which was made available to persons who believed that this was the way that their health care and their religion should come together. the amendment does not mandate coverage for any particular health condition or benefit. it does not interfere with the secretary's prerogative to determine which patient conditions will be included in minimal qualifying coverage. i support the amendment and urge my colleagues to do the same. >> now i'd like to yield to my colleague from wisconsin, ms. baldwin. >> thank you, mr. shimkus. i want to add my support to this amendment and say that for me in addition to knowing of many constituents who are concerned about the addition of these

protections in á@@i&h#x x somebody who openly became a role model -- a young woman legislator who was a christian scientist. over the years, she has given me a quick study in the importance of including spiritual care in any comprehensive package. precedent exists for these services, and try-care, other programs, so i commend the gentleman for bringing this forward and i had my support. >> would the gentleman yield to me? i thank the javelin for the amendment and i agree we should endeavor to ensure the bill not discriminate against any religion. against religion. by the same token, it's important to make sure we don't require the coverage of one particular religious benefit at

the expense of another. i support the amendment and will urge its passage. >> i thank the chairman and yield back my time. >> are we ready for the question? all those in favor of the shimkus amendment say aye. aye. opposed no. the ayes have it, and the amendment's agreed to. mrs. baldwin, do you have an amendment? >> yes, mr. chairman, i have an amendment at the desk. 05. >> clerk will report the amendment. >> amendment to the amendment in the nature of a substitute offered by ms. baldwin of wisconsin. >> and others. without objection, the amendment will be considered as read, and the gentlelady's recognized for

5 minutes, and i would ask members -- >> could we reserve a point of order on it, mr. chairman? >> gentleman from texas reserves a point of order. i'd ask the members to pay attention to the speaker and recognized gentlelady for 5 minutes. >> thank you, mr. chairman. i am honored to offer an amendment that serves to unify us. despite the diverse perspectives represented among progressives like myself, moderates and blue dogs. our members have worked together to find innovative ways to save additional dollars in health care allowing us to address some of our differences and to restore the subsidies that we offer to middle-income families to make sure that premiums are more affordable for all working families. i'm proud of the way our unity package has come together, and i will attest to the fact that my colleagues and i have been negotiating around the clock quite literally to get to this

point. over the past few weeks, our committee has seen movement followed by impasse followed by breakthrough followed by more impasse. mr. chairman, it is my hope -- >> committee will, please, come to order. >> mr. chairman, it is my hope that this unity package represents the final breakthrough that leads us to advance health care reform. this amendment is a powerful response to the naysayers, the cynics, and the keepers of the status quo, and by adopting it today we will demonstrate that congress is capable of bridging our differences to finally make reform of our health care system a reality. it represents a common goal, to advance national health care reform legislation out of this committee, out of the house and see it signed into law this year. that is what the american public expects of us, and we agree the time has come. many of my colleagues contributed significantly to this package, and i would now like to yield to a couple of

them. i'll start with my friend, congresswoman kathy caster. >> thank you. one of the ways we are going to lower health care costs for american families and hold down the cost to government is to lower the prices of prescription drugs. so my, my portion of this package is an amendment that grants the hhs secretary the authority to establish a form lair within the public action. a form you lair is a list of drugs and pharmaceuticals. cbo has informed me that the amendment is a cost saver and, in fact, representative harmon bird dogged the cbo directer to get him on record here as well. lower drug prices pursuant to a formulary in the new nonprofit public option places our new public option on a level playing field with the private health insurers that already establish their own formularies.

i thank my colleagues and yield back to ms. baldwin. >> thank you. i'd now like to yield to my colleague, chris murphy. >> thank you very much, ms. baldwin. there's an important piece in this bill which gets at the savings we can achieve from administrative simplifications by making more of our transactions electronic. we could potentially save $10-15 billion in our health care system, something that representative gore done has worked on as well. in general, though, i'd really like to thank ms. baldwin for her work here. there's a lot of agreement that we need to squeeze every possible dollar out of this bill, but not at the expense of the people we're trying to help, not at the expense of the folks we're trying to get hooked up with affordable health care insurance, and this package points a very clear and workable way forward to squeeze this money out of our health care system but do it in the right way, and i thank all my

colleagues for their work on this amendment. yield back. >> i would now yield to ms. harmon. >> i'm so happy to be part of this team that is bringing this unity amendment and then the next unity amendment before the committee. and just want to comment further on the, on part of it. and say that we're not just talking about cost cutting when we set up a formulary, but also better care. this is what members of congress have. our private plans are managed by pbms, and to emphasize something. [applause] castor said, when he was before us, doug elmendorf said the way to cut costs was to establish a drug formulary and let it negotiate for drug prices and this way we will bring drug costs down in a quality environment, and i just want to, finally, ask the chairman is --

i would hope that this would be done in consultation with usp. i know this is something you have considered, and i'd ask the amendment sponsors as well. the us farm cope ya. i just want to be sure we're using established practices as we set up the formulary, or maybe i should ask any of the sponsors of the amendment just to be sure we are creating that legislative history. >> thank you, ms. harmon, and with that, mr. chairman, my time has expired, and i yield back. >> are we ready for the question -- >> we have some time in opposition. >> oh, yes. mr. boarton, i heard your -- barton, i heard your side screaming for a vote. >> well, at least let us tell you why we're opposed to it before we get rolled on it. i oppose it, i won't say everybody on our side opposes

it. i give the blue dogs credit, they did try to cut costs a little bit, and hopefully that amendment will. it would seem to me this amendment is going to raise costs. it creates a pilot program for medicaid where the secretary would be allowed to increase the federal match dollars up to 90 percent for the first two years and 75 percent for the next three years. this formulary that has been discussed -- >> would the gentleman yield on that point, on the pilot project? >> yes, ma'am, i'll be happy to. >> this is one of my contributions to the bill, and it would actually be a cost reducer. right now there's a pilot in medicare for accountable care organizations that is projected to save $2 billion over ten years. this, if we extend it to medicare, would produce additional savings. of course, some of those would accrue to the state, some to the federal government, but that is what we expect to be the results of this measure. thank you. >> well, i appreciate that, and i hope you're right, but when you allow for increase in

expenditures, it's hard to see how that's going to end up decreasing. but maybe it will. the formulary the federal trade commission and cbo has looked at that idea, and they indicated that if it had been part of the original part d, it would have probably increased medicare part d costs 10 percent. >> will the gentleman yield? >> i'll be happy to yield to the gentlelady from florida. >> on that point, that's not accurate. it was confirmed here by the cbo directer at the -- in response to congresswoman harmon's question, mr. orszag has also confirmed it. i think the difference is through a formulary it's more akin to the v.a. system where they're really able to save a lot of money. and, in fact, cbo commented on this and said just this morning, yes, this saves cost.

>> okay. well, we think that this amendment, if adopted, is probably going to increase costs. we do appreciate the intentions of the@@@@@@@@@ @ @ @ @ @ @ @ ' >> it's a shame that is brought to us this way. this project was started in the last administration and has been nothing short of spectacular in its delivery of savings. from a commission standpoint, if you practice with a formulary, you would not be happy about going that -- going back to that. i lived with that under parkland hospital and was the most egregious thing. i was so grateful when it was said that there will be six classes of drugs protected and will be at least two choices within those six classes. that is what has led to the

success of the program and high peso -- high patient satisfaction. now the secretary of health and human services will determine the formulary. oftentimes, one size does not all. the more we find out about the madison, the more we find out it needs to be more personalized. going to have one oral contraceptive, only has one option for estrogen replacement after menopause, only has one option for treatment of high cholesterol as we find in other european countries who exist under a formula, i think you're going to find your clinicians unnecessarily restricted. and just on the point of pbms, we went through this and went through enormous effort to try to not hurt the community pharmacists when we went through the medicare part d program, and in spite of that effort, many of them still felt they got the short end of the deal. with what i see in front of me

today, i think you're going to be hearing from your community pharmacists, i hope you do, because what you've got outlined on this paper is truly going to eliminate the mom and pop pharmacists that so many of our patients depend upon to get not just medical devices and pharmaceuticals, but also device. i thank the ranking member, i yield back to the ranking member. >> i yield to doctor diehl the last 20 seconds. >> thank you. i'd like to ask counsel, first of all, does the public option come under the definition of a qualified health benefits plan? >> yes, it would. >> so all of the reporting information that starts on the top of page 4 of this amendment as to the volume of mail order and retail pharmacy prescriptions that are filled, all of the disclosures about price concessions, etc., the public option would be required to make those same disclosures?

>> those disclosure requirements refer to information that the pbm, pharmacy benefit manager, used by a plan should the plan use one have to report to the plan and to the commissioner. >> and that would include the public option? >> that's correct. >> that's, that's all the questions i have. i yield back. >> gentleman's time has expired. are we ready for the question? all those in favor of the baldwin amendment say aye. ay opposed no. >> no! >> the ayes have it. the amendment's agreed to. >> ask for a roll call vote. >> you want to do a hands? >> let's -- yeah, we'll do a show of hands. i don't see a -- >> that's -- [laughter] all those in favor of the amendment, please, raise your hand.

[inaudible conversations] >> the clerk have the vote? all those opposed, please, raise your hand. [inaudible conversations]

>> clerk will announce the vote. >> mr. chairman, on that vote there were, the division vote was 50 ayes, 25 nos. >> 30 ayes, 25 nos. >> i think i'm going to ask for a roll call vote. i didn't count 30 hands raised. >> clerk will call the roll. >> mr. waxman? >> maybe we shouldn't do it on closed vote. [roll call]

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[roll call] >> have all members responded to the call of the roll? any member wish to change? his or her vote? clerk will tally the vote and announce it. >> mr. chairman, on that vote there were 32 ayes and 26 nos. >> 32 ayes, 26 nos. the amendment's adopted.

[inaudible conversations] mr. shad keg, do you have an amendment? >> i do, mr. chairman. it's number 2b. [inaudible conversations]@@@@ >> of the clerk will report the amendment. >> -- the of them and is considered as read and the gentleman from arizona is recognized for five minutes.

>> thank you. in the midst of this debate, we have a tendency to miss what is good about american health care. medical innovation, drug development, expedition -- expeditious this and other things of made the united states of the world leader in breast cancer treatment at all forms of cancer treatment. shows, the five-year survival rates in the united states for all men's cancers are better than those in canada, europe, or england. it is also true for all women's cancers that our five-year survival rates are better than in canada, europe, or england. the focus of this particular amendment is breast cancer, but before we go there, i want to mentions to tate cancer. -- prostate cancer. the survival rate, five-year survival rates in the united states as this graph shows taken

from studies done by con concord, the five-year survival rate in the united states is 91.9 percent. in britain, by contrast, it's 50 percent. dramatically lower. the amendment i have put before you focuses on breast cancer. we have a saying in the shadegg family, anytime or any day on which neither a member of the family nor anyone we love is diagnosed with cancer is a good day. i think cancer is the disease about which americans are most concerned, and i'm pleased to have support on this amendment from my colleagues, mrs. myrick of north carolina, and mrs. blackburn of tennessee. this chart shows that breast cancer survival rates in the united states, again, are significantly better than in canada or in europe or in england, and i would hope we would want to preserve that. and so what the amendment simply says is that once a year the government accountability office would conduct an annual study

concerning breast cancer survival rates and reveal that information and that if in any one of those studies it turns out that breast cancer survival rates in the united states are declining by more than 1 percent, one tenth of 1 percent, then women in the united states could choose to pick a plan that focused on breast cancer, a plan that devoted resources to preventing and/or treating breast cancer or otherwise focused its efforts on this terrible disease. i think it's a reasonable step, it's an effort to make clear that we are concerned ant this disease, and with that i'd be happy to yield to my colleague, ms. myrick. >> i thank the gentleman. i'm a nine-year breast cancer survivor, and i was a beneficiary of the health care system and the fact that literally i was able to see six doctors all total, have three mammograms and an ultrasound before it was finally diagnosed because i knew something was

wrong. and in other systems, i would not have had that benefit, so it's extremely important that we do everything we can to protect this in this bill that was sure that there is no decrease in the advantages that cancer patients have now today and that they will still have those under this plan the way it's described today. thank you, and i yield back. >> i thank the gentlelady, and i would now yield to my colleague from tennessee, ms. blackburn. >> i thank the gentleman for the amendment and for what the amendment accomplishes for women. i think one of the greatest fears for women as they are looking at what would happen with a transition to government-run health care, they fear what would happen to their care. especially if they have a risk of breast cancer or if they are survivors. and there are five things that this bill would do that are important to breast cancer survivors. number one, in no way would the care be diminished that a breast

cancer patient is entitled to receive. number two, it's the gao study that mr. shadegg mentioned making certain that they look at the changes to the five-year survival rate. it would require, number three, the secretary of hhs to annually certify that no decrease in those rates has occurred, and number four, if they do find a decrease, the amendment allows women and their families with female members to purchase benefit mandate free coverage of their choice, something that would meet their needs and also address their fears. and, fifth, it would make certain that they are not forced to buy expensive essential benefit insurance that would include items they do not need. i thank him for his leadership, and i yield back. >> i thank the gentlelady for yielding back. my oldest sister is a 20-year breast cancer survivor. i praise the fact and am thankful every day that she has

survived that disease. i think this is a reasonable amendment, i hope we'll adopt it, and i urge can committee to do so in the strongest possible words. >> would the gentleman yield? >> gentleman's time has expired. and i -- who's seeking recognition? well, the chair will recognize well, the chair will recognize himself. similar to the other amendment amendment -- this amendment uses the, is really sounds good but has a little hook to it. it states any family with a woman in it, which basically means almost every family, can choose a plan that is exempt from minimum benefit requirements if the overall breast cancer survival rates go down by .01 percent in all private and public plans. now, the connection between a 0.1 percent decrease in the five-year survival rate and

minimum benefit requirements is a weak causation at best. the reason the bill has minimum benefit requirements is because too many private health insurance plans don't cover the necessary services and treatments that people need. and that includes breast cancer patients. i think one of the main reasons we're doing health reform is because people are sick and tired of paying for health insurance and believing that when the worst scenario happens, they're covered. that's why the bill, the underlying bill will require that all plans can no longer exclude coverage because of pre-existing conditions or stop paying for services because of annual and lifetime caps. insuring that all plans have minimum benefits means that americans can rest assured that they're getting what they pay for, and if the worst case happens, then they will get the

medical care that they need. this amendment is disingenuous, it will only lower the quality of care for the millions of americans counting on us to finally insure health insurance companies by giving us the services we thought we paid for. i urge the opposition to this amendment. and i yield to you. >> thank you, mr. chairman. i just wanted to ask the maker of the, of the amendment what breast cancer advocacy groups are supporting the bill, if there are any. >> i was not able to run it past any breast cancer survival groups. this is my idea. we've been working on various amendments. i would like to point out that while the chairman read the word minimum mandates repeatedly, in point of fact it only exempts them from those benefit mandates in section 124, titles which is

recommendation and adoption of benefit standards. i don't believe some of the benefit standards that the chairman referred to are, in fact, in that section. >> chairman? >> with that, i'd be happy to yield back. >> mr. green. >> mr. chairman, having read the amendment and i appreciate you yielding to me, the concern i guess i have about it is that the reason this, we need this bill is we need to have a health benefit mandates. those of us who have served as state legislators know that there are certain problems with, in certain states that you will buy an insurance policy, and you assume it covers something, but if it's not on the state minimum benefit mandate, it's not there. and i'll give you a great example. my first term in the legislature in texas, we had a bill that would mandate health care for newborn children. the standard state insurance policy did not take in the children for the first 21 days

in 1973. so there's a reason that we have minimum benefits, and i would hope that whatever this -- our agencyokrr that is why i think the amendment is a bad choice. thank you. >> thank you mr. chairman. having grown up with the number of women -- a number of women who have died because of breast cancer, i think i have come to the realization that preventative medicine is probably the most important gauge and not a matter of

whether it is a good plan are bad plan. would at least allow us going forward in the future to provide for some method to analyze what's the best way to de-- detect, what's the best way to get women in for annual mammographies and to do the things that are necessary. >> i reclaim my time. i i want to agree with the gentleman. that's a very important reason why we need this bill, and we need to do more in this direction, but what this amendment does is try to exclude the ability of people to get the full range of benefits. i urge opposition. are we ready for the question? all those in favor of the shadegg amendment say aye. opposed no, no. >> on that, mr. chairman, i request a roll call vote. >> how about hands? >> no, sir. >> roll call vote, please. >> clerk will call the roll.

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>> have all members responded to the call of the roll? any member wish to change a vote? mr. murphy? >> mr. murphy of pennsylvania votes aye. [inaudible conversations] >> the clerk ready to report the vote? >> yes, sir. mr. chairman, on that vote there were 22 ayes and 36 nos. >> 22 ayes, 36 nos, the amendment's not agreed to. ms. schakowsky, you have an amendment. >> i do. i have an amendment at the desk, premiums and drugs offered to division a. otherwise known as unity 2.

>> clerk will report the amendment. >> amendment to the amendment in the nature of a substitute to hr-3200 offered by -- >> without objection, amendment is considered as read. gentlelady from illinois is recognized for 5 minutes. >> thank you, mr. chairman. i'm pleased to offer this amendment on behalf of representatives castor, sutton, wiener, capps, baldwin, sarbanes, bradley, matsui and gette. i marley want to thank any -- particularly want to thank my co sponsors. we have been working in this markup to make -- >> mr. chairman, the committee is not in order. >> mr. chairman, the -- >> gentlelady's correct, committee is not in order.

the author of this amendment deserves the courtesy of having members listen to her. >> we've been working on this markup to make health care more affordable, and this amendment will help us in three ways. one, it will help prevent excessive premium increases by limiting annual increases and premiums for exchange participating plans to 150 percent of medicalnflation. two, it addresses the need to have medicare negotiate rates in order to lower part d drug prices. third, it provides that the savings achieved through these two provisions will be used to lower premium costs for consumers in the exchange. i want to explain further i want to yield to my colleagues, first mr. murphy, mr. welch, ms. harmon and ms. degette. mr. murphy? >> would you like to yield to them one minute each? >> that'd be great. thank you. >> thank you very much, and i'd like to thank my co-sponsor,

ms. schakowsky. our biggest insurer in connecticut announced a couple weeks ago they were going to raise rates by 32 percent on individuals and maul businesses. -- small businesses. luckily, we have the ability to g@ @ h a& @ @ @ @ @ da,h@ @ hs the amendment allows for that same mechanism to protect not only businesses or individuals who purchase insurance but the federal government will pick up some of the cost. we are looking for ways to not only protect the underlying cause for the government but to protect our consumers as well and as we try to find ways to offset some of the potential increases in the cost to consumers that were included in the previous amendment, i think this is a common-sense way to find savings both to the federal government and to individuals by making sure that we are not

passing along excessive premium increases on an annual basis and i yield back. >> through next? >> thank you, mr. next -- thank you mr. chairman. it buys wholesale but pays retail. this would require services to negotiable price discounts in purchasing burke -- in purchasing all prescription drugs. this was passed in 2007 but right now medicare pays more for prescription jogs -- prescription drugs than anyone else. just a few examples -- one drug, $300 for the v.a., $1,400 for medicare. another one, the list goes on. t d program is 58 percent higher. the oversight and government

reform committee, mr. chairman, did a study last year that said if we had price negotiate, it could save the taxpayers $156 million. we want price negotiation on the doughnut. the president has done it on the doughnut hole. i yield back. >> next is ms. harmon. >> i thank the gentlewoman for yielding and am pleased to be part of unity amendment 2. and unity amendment 1 we passed the requirement that there be a formulary in the public option. that was a piece of the so-called care package which a number of us introduced several weeks ago. this amendment contains another piece, and that piece is to repeal the ban on negotiating drug prices under part d of medicare. there are a number of new members in this committee. they were not there as the oldies were at 3 a.m. on -- not here at 3 a.m. on november 22, 2003, when an amendment was kept

open for four hours to ban the secretary of hhs from negotiating lower drug prices. it ultimately passed after many kneecaps were broken by 220-215. this amendment will fix what was broken that night. i yield back. >> ms. schakowsky, anybody else you -- >> yes, ms. degette. >> i just want to close, mr. chairman, by thanking everybody and the blue dogs for working together on this package of three unity amendments. and i want to say about the last two amendments this hasn't really been focused on. both of those amendments have a clause which says that any savings that we realize from these amendments will be used to apply to, to the premiums. they'll be used to go towards making premiums more affordable for lower-income people in the health exchange by offsetting the reductions in premium

subsidies under the blue dog amendment. this is a great example of how this committee can work together, mr. chairman, and we're all really proud of our efforts, and we're proud that this bill will move forward to the floor. with that, i'll yield back. >> time has expired. mr. blunt? >> i'd like some time, mr. chairman, thank you. i guess this is the amendment that we almost debated earlier that my friend from vermont had. i'd just can like to make a couple of points i made then. one is that this committee asked , the majority asked the cbo directer when he was here if government negotiating for drugs, government negotiating as this amendment would suggest would save any money. he said, no, that's -- i don't know that there was a record of that meeting, but it was well attended, and the members were here. i did check that part d participation in people who have v.a. coverage, this is coverage where do government does -- the government does negotiate for

drugs 40 percent of people who have v.a. coverage, that's 1,225,900 people, chose to go into medicare part d because they can get the drugs they want. you know, the only way to negotiate, for the government to negotiate for drugs is to be willing not to offer. now, the difference in private companies negotiating is they negotiate different combinations of drugs. i certainly appreciate the numbers, the price numbers my friend gave on what you could pay on part d under some plans. my, my guess would be that that is not the lowest number that you can pay, but the highest number you can pay. and certainly not every company that's negotiated medicare part d has negotiated the lowest possible combination of all drugs. that's why if you're finding your drugs under medicare part d you need to look specifically at the drugs you take which if there are two of you at your house, many, many times the two spouses do not find the same

company unless they happen to take exactly the same drugs. certainly, there's some companies that have not negotiated well for these prices at all. and if you find -- and that's not the company you should choose. so i just think there's no evidence that this is a good idea. my friends on the other side have wanted to do it from day one. at one time in this committee we suggested that the, the price for medicare part d would be $35 a month. the year medicare part d started the lowest average price was $24 a month, and every year since then it's been 40 percent below the projected level. marketplace works, the government is not a good negotiator, the government's only a good negotiator if you're willing to have a very limited amount of drugs. and apparently in the biggest area where the government does negotiate those people that have that coverage already have gone to the extra effort to get the medicare part d coverage to the

tune of 40 percent, over one million people in v.a. have opted to make the effort to be in in medicare -- >> would the gentleman yield? >> first yield our 5 minutes to anybody over here. >> would the gentleman yield? >> thank you very much for yielding. the v.a -- please, the v.a.'s formulary has always been under attack since i've been here, and even before i arrived under the democrat-controlled congress they thought this would be a good idea, to extend the v.a. pricing. do you know it was repealed within six months? it was repealed. it was repealed because of the impact of pharmaceutical pricing. so it is really challenging. pharmaceutical companies do have multilevel pricing with regard to their drugs, and even government purchasing of those drugs. the v.a., we have the lowest with regard to our purchase of drugs, and why do we do it that way? because it is a very precious and sacred population. the men and women who have sacrificed for us and our

freedoms. so we have said that we're going to have a very special population, and we actually go in there and we'll dictate under these manufacturers what type of price we're willing to pay. at the same time, a lot of these manufacturers will also come back and say, you know what? we'll even go lower than the federal supply schedule. now, why would they do that? they do that because many of our hospitals are also teaching hospitals, and they want their pharmaceuticals to gain access to those new docs. they want to know the value of those pharmaceutil products. my only charge here is to all the members, we've looked at this before. .. are to a summary, using its personal power for purchases

provided by the program the federal government receives discounts from drug manufacturers. extending federal prices to medicare beneficiaries could result in paying less for drugs, but these lower prices will come with a trade-off. federal and non-federal purchasers will pay more when drug manufacturers raise prices to offset revenue losses resulting from extending those prices to medicare beneficiaries. that is it correct -- that is what occurred when the congress took the action to extend other contracted powers of government. please, let's not recreate this all over again. it may be sounding like a good idea, but it does not fit. i make the appeal -- please do not do this again. i yield back.

>> all time has expired. the vote now occurs on the amendment offered by tchaikovsky -- that is offered. let's go for the roll call. [roll call] [roll call] [roll call]

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t@e@@@@ @ @ @ @ g& make. >> mr. hall. >> mr. chairman --

[inaudible conversations] >> do we have all amendment? [inaudible conversations] mr. paul, can you identify your amendment? does it look like this? >> i had hall wan and hall hall-2 and this may be hall-1 or hall-2 on medicare advantage.

>> [inaudible conversations] >> it's hall-1 i think. [inaudible conversations] >> has the clerk located -- >> we have. to the amendment in the nature of substitute to h.r. 32 -- >> without objection the amendment will be considered as read and mr. hall is recognized to explain his amendment. >> i will be very brief because i think the committee is aware of the fact that the proposed bill, the bill we've been working on for several days cuts medicare advantage by roughly $156 billion, and my amendment simply reduces the cuts by half.

now, we had a vote earlier on reducing the entire $156 billion, but that failed by a fairly close vote and i am trying now just to cut by 50%. actually current provisions in the bill are going to result in reductions and medicare advantage funding by more than 20%, and a lot of the areas likely limit seniors to access, to coordinated case through the medicare advantage program is going to be limiting on them, and really we ought to be making cuts to the program ought to be developed in a fair and equitable manner to provide medicare beneficiaries with better access, put the program on a more sound financial footing and preserve opportunities by medicare beneficiaries to enroll in plans across the country. just very briefly let me quickly

say that in the far eastern district of mine, one of the counties in my district, it would cut them some hundred $75 there is an enrollment of around 1600 people. but in the smallest county in my district, it cuts it by $220, and there's only i think 58 or 68. it's a very small county. a county like bear countyas 64,000 enrollment. it cuts roughly $230 per medicare advantage beneficiary. same thing for harris county. it cuts about 220, and there's 13,977. i yield the rest of my time to the gentleman from indiana who has good figures on this. >> i thank the gentleman for yielding. the medicare advantage plans are an important options for seniors and have lower out-of-pocket costs for seniors. the cover more services than traditional medicare including vision, dental, a hearing benefits as well as prescription

drug benefits and better preventive care. i propose the cuts the democratic majority have offered to medicare advantage. i believe such cuts would have a devastating impact on beneficiaries and loss of coverage. this is a very popular program from 20042009 over 1 million beneficiaries and rural area joined medicare and vantage come increase of 507%, think about how many are in this program in indiana, over 148,000 hoosiers are enrolled in the medicare advantage plans. so what i did is i thought i would take a look at some of the members here and have any beneficiaries they have in the district that will face these devastating cuts for programs they feel is pretty important. in indiana mr. hill rounded off to 100, mr. hill has 14,100. mr. speakes has 24,000. mr. matheson has 31,200. mr. allyson has -- mr. ross has

13,900. mr. bartsow, mr. enzi has 22,000, mr. gordon has 23,900. mr. boucher is 22,100. mr. gonzalez has 31,000 lines of dtv and mr. stupak has 30,438. it should these cuts be enacted? thousands and thousands and thousands of seniors will stand to lose their coverage, and leading them without important health care coverage and options , and i just think that it's wrong and there is a better way to handle our seniors than this way. i yield back -- i will yield to dr. gingrey. >> i thank you for your presentation. this is chronic disease -- who wants time? mr. gingrey, dr. gingrey, i yield to you the remaining amount. >> i thank the gentleman from texas for yielding amendment

earlier fee-for-service and just episodic care and that is why it is a little bit more expensive, but in the long run, theoretically it would save a tremendous amount of money. and so, the cots, yes, sure we should cut and try to reduce the cost, but i think we have cut way more out of it than just the fact. we've got the mosul of the bone and i agree with the amendment of mr. hall and yield back. >> this kutz 10% rather than 20%, and i will yield to anyone that has questions. >> i yield back my time. >> the gentleman is time is expired and the chair would oppose the amendment. it would result in adding $50 billion to the deficit or require -- it does not require reductions to the bill, but they

would -- it would cause a problem and i know that you are concerned about the cuts we are making to the medicare advantage plans, but i think the cuts in the bill are justified and i urge members to oppose the amendment, and i would like to go to a vote because it is late -- >> mr. chairman? [inaudible] >> okay. mr. inslee, one minute. >> mr. chair, many areas of the country that have suffered from a low reimbursement rates and on fewer geographic distribution have rely on medicare advantage plans, and there are concerns about this. but the good news is that we have been working with the speaker of the house who has been helping us find ways to solve this. some of which is not in the jurisdiction of this committee and i am fairly confident that we will succeed in finding some bridge to helping other communities to the new medicare

reimbursement system that will provide high-quality and will provide adequate reimbursement rates and i am confident we are going to hit in the direction. it may not be tonight but i feel good about that and i want to ask the chair if he will work with us with the speaker to continue those efforts. >> the gentleman will yield, absolutely we want to work on that and i think it's imperative to work it out before we have the bill on the house floor. republicans are asking for a roll call vote; is that correct? the clerk will call the roll. [roll call] [roll call]

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sweetened with ploch [roll call] [roll call] [roll call]

>> mr. r roche, how do you wish to go to? [roll call] >> mr. murphy of pennsylvania is not recorded. mr. murphy oats ayes. >> there are members over here that wish to be recorded. >> [roll call] >> have all the members voted?

anyone wishing to change their vote? tally the votes. are you ready? >> mr. chairman, ayes 27 and nays 31. >> 27 ayes, 31 nos. the amendment is not agreed to. christianson has an amendment. >> this is an amendment to the territories. i hope the question -- we have the correct amendment? >> without objection the amendment will be before us. >> we are ok with it. we accepted. >> the republican side accepts the amendment. all those who favor it, say aye. the ayes have it. >> we have a new amendment at

the desk. >> it says the purchase appears -- the burgess appeals medication. it is a bipartisan -- >> without objection it will be considered as read. i understand this is an amount of non-controversial items were agreed to items. if that is correct anybody have anything to say about it? let's proceed to a vote. all of those in favor of the amendment will say ayes. opposed, know. the ayes have it and the amendment is agreed to. the democrats -- mazar degette, you were going to ask -- >> i have unanimous consent request. >> please state your unanimous

consent request. >> through the market we have had time limitations and many members have had statements they've not been able to make on both sides. i would ask unanimous consent any member may enter into the record statements and materials relating to their amendments that they were not able to enter. >> without objection that will be the order. >> we have no objection to that. >> democrats will take a brief caucus and 23, 22 and we plan to be no more than 15 minutes and then return for the markup. [inaudible conversations]çñç

we have 55 to 60. if we try to process all of

those amendments tonight, we will be here quite late. so we are going to have the unanimous consent agreement that after we report the bill tonight, assuming we report the bill tonight -- >> if we report the bill tonight. we have to vote. >> after the bill as reported on successfully -- [laughter] then we will come back in september and bring up other bill which will reflect the amendments that we agreed to and then amendments can be offered said that -- to that. but only those on the desk prepared by the democratic and republican staff. we are not in the business for

new amendments to come into our hands in august because it will not be permitted. we will only be considered the most considering the amendments on the list with the caveat that we both agreed to add additional amendments. we both have to agree. >> reserving the right to object. >> yes. >> you and i have agreed to work on new amendments with regard to the preserve. if we are able to work that out i reserve the right to offer that. >> i believe so. >> i withdraw my objections. >> i want to see -- >> i agree with that, mr. chairman. we have had a long marked up. nonproductive, but interesting. having said that the majority has worked its will and a wondrous way from a technical

standpoint. i agree that the amendments are posted. plus any other amendments that you and i agree to be for now and then should be offered. i am willing to have that marked up in september on an expedited basis. i think that freeze members to go on to their august work -- frees members to work. >> these other amendments could then be sent to the rules committee to be added to the legislation and of course, if we are not able to do another bill for another reason, the authors will be able to go to the rules committee all we could try to pack it some together for an

amendment that we would offer at the rules committee. >> what i am agreeing to is that members on your side, especially, because there are so many additional amendments have gone through the process, have posted, were ready to offer them, will be given an opportunity in september to have those amendments in an expedited fashion. >> then we will proceed on that basis unless there is objection. hearing no objection, that will be the order. i want to acknowledge the man who has worked so hard to get affordable health care for 53 years following the efforts of his father who preceded him in congress. the main author of the bill is john dingell. we all should applaud that.

[applause] i want to thank the staff who has put in so many hours, an unbelievable amount of time, working so diligently. i will not name names because of all make a mistake, but there is one person i want to sing aloud. that is our staff director for health, cary nelson. [laughter] -- [applause]

i am going to recognize mr. barton in one second but i also want to recognize -- >> you have put me on the spot, mr. chairman. it is my job to put you on the spot. if we're going to acknowledge that as we have to acknowledge the minority staff. we are like ginger rogers -- we have to do it backwards and in high heels because we are so shorthanded. our staff director, mr. david kavick, and our health cancels -- counsels, brandon long. we should give them a round of applause, too. [applause]

and we actually won a few amendments. >> i would be it remiss if i did not paid tribute to our brilliant staff director, who has done such a wonderful job, phil varnett. if we did not have the house legislative council, jessica shaprio, ed grossman, and another dozen members helping, we would be in brackets, now here. [applause]

>> i guess i should think the house parliamentarian. -- thank the house parliamentarian. he did rule our way one time. >> on behalf of all of the numbers, wiehl thanks to our own staff to work many hours as well. -- we owe some thanks to our staff who worked many hours as well. [applause] >> having completed the amendments -- >> there has been one omission in terms of people who should be thanked for completing a historic piece of legislation. the first time it has happened

in this committee and the first time it has ever headed to the floor of the house of representatives, and that is you. your historic leadership has brought us to this point. we all want to thank you for giving us this great opportunity to participate in history with two. thank you. [applause] >> thank you, all. thank you. procedurally we have before us the bill was amended -- as amended. all those in favor of the manager's amendment as amended will say aye. opposed, no. the ayes have it.

do you have the motion? >> i have a motion i would like to make, mr. chairman, that the bill be reported by the committee with the usual instructions. if i could be recognized briefly in support of that emotion -- of that motion i would be appreciative. first of all, congratulations. you have done a superb job and you have every right to be proud, of you and what you have done. i am sure everybody in this room joins me in those good feelings. to my colleagues on both sides of the aisle, congratulations. thank you. to the staff on both sides of the island to our personal staff also -- thank you and congratulations. there's somebody down there in the legislative council. they have a particular word of

thanks. they are one of the things that has made this body out shine our dear friends in the senate. [laughter] we, the members, and our other staff speak of that. it is a great bill, mr. chairman. i move that it be reported with the usual instructions. an thank you for the fine work and leadership you have given us. >> the clerk will call the roll. this is on reporting the bill as amended. [roll call]