the other way. host: how does it work for you on the cases being heard? are you able to be in the hearing room itself? will you be listening by broadcast? guest: there is a press gallery. they will not let c-span in, but they will let pen and paper reporters in. we set off to the left, quite close to the justices. it will be a very interesting argument. host: thank you for setting the stage for us. "washington journal"will be here every day throughout the holiday weekend. we hope you will spend some time with us. have a good holiday. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] . .

>> you are watching c-span, created for you as a public service by america's cable companies. next, highlights of the senate committee's debate on health care legislation that took place earlier this summer. then a look at how the u.s. has recovered from recession since world war ii. then marks from gordon brown on security in afghanistan. -- then marks from gordon brown. -- remarks from gordon brown. >> september 1 marked the 70th anniversary since the start of

world war ii. there was a celebration including angela miracle -- angelamerkel. >> what is the best way to secure america? tom ridge takes an inside look at the terrorist threat. and what led to his resignation? that is part of a "book tv" weekend. >> national book award winner jonathan kozol has critique the public education system. on "but tv -- book tv.tions live >> i move to report the bill as amended. [applause] >> that is chris dodd from july

15 announcing the passage of health-care legislation after 13 days of debate in the health education, labor and pension committee. the measure passed with all democrats in favor and all republicans against. over the course of the next three hours we will show you a sampling of the debate that took place. joining us to talk about what is in the bill when congress returns from its recess is shailagh murray. thanks for joining us. that committee is one of the five senate and house committees working on the health care bill. we start off by giving our audience an overall picture on where we stand as congress gets set to return. >> four of those five committees have acted at this point. there are three committees with jurisdiction over health care and in the senate there are two.

the finance committee is the only one that has not completed its portion of that particular bill. reason being that health care encompasses so many different policy areas and finance, it oversees the taxing, medicare, medicaid portions of the bill. whenever there is money involved it takes longer. it is tougher to find consensus, but the health committee bill we will talk about has most of the policy. wellness prevention, a new framework for how people can buy health insurance and also guidelines for how to subsidize it. in the house, the three committees have acted. it was pretty ugly at the end getting it through the final committee.

house leaders will wait and see what happens before they moved that bill to the floor. they will have to rewrite the bill before it gets to the floor because of changes that were made. while health care reform is farther along than it has been in a generation come it is -- farther than it has been in a generation, it is just a big bill. >> we will focus on the senate health committee version. we touched on a couple of bullet points. what else is notable about this bill? >> the health committee's bill is the most straightforward, because it outlines -- a lot of folks don't understand the scope of this legislation. the health committee bill and a series of titles out lines how employers are going to be penalized for not providing --

what size companies will have to provide coverage? what happens to employees if they do not? this will establish an individual mandate requiring people to buy health insurance. the finance committee has to create the mechanism for doing that but the health committee sets forward the policy. there are provisions on how to encourage and create incentives to get people to do the check ups and detect diseases like diabetes, which have set such enormous public health costs -- which have such enormous public health costs. a key to lowering health-care costs long term, which is the underlying goal, is to get a handle on these diseases and try to intervene with them before they become explosive cost

issues. >> you have two different committees on the senate side working on their versions. tell us about the process. once the finance version is finalized what is the next step? >> the finance bill has to emerge from the committee mid september. at that point, senate majority leader harry reid said he will create a committee or group of individuals to combine these two bills in order to put them on the senate floor. that is a process we usually associate with the end of the legislative process, but you cannot put both these bills on the floor and let the senate worked its will. >> that opening video was notable because senator dodd was in the chair for senator kennedy.

what has senator dodd -- what are his plans? >> we expect him to become the chairman of that committee. he has not indicated his preference at this point. he could remain chairman of the banking committee if he wants, but he has the seniority to take over that committee. he was very close to senator kennedy, and this week senator reid tipped where senator dodd was leading when -- where he was leaning when he thought he would become chairman. we don't expect that to happen until after congress returns. >> it has. i think a lot of people see that moment as an opportunity to

reassess this effort in a broad sense. it was distilled down to a lot of flash points over the recess. none of them were central issues to this effort, but i think people will have an opportunity to reconsider the magnitude of this effort. also, the way senator kennedy went about things, which over the course of the career earned him the respect of many of his colleagues, including a lot of republicans. >> one of the flash points was the mention of the worst public plan. in a moment we will show some -- the mention of one of the words public option. >> it is the centerpiece of this health committee bill.

it is the flash point of the debate and yet most people don't understand what it is. it is a government-backed health insurance option that would be offered in all markets in some form that would allow or at least provide a minimum option for people who don't have health coverage to purchase it so that they would not be forced to buy a more expensive private insurance plan. the idea is to introduce a consistent form of competition across these markets. and create some consistency in the way that benefits are is administered and offered so that people know what to expect. people in montana have the same options as people in new york.

that is the idea. to many people it sounds like the government moving further into the the committee passed the bill on a party-line vote. what about that particular element? does it have any republican support? >> not really. a lot of democrats are uncomfortable with the idea. one of the big holdups in the house and big challenge going forward for the house bill will be this public option. >> we will take a look at 20 minutes of debate on the public option from the senate health committee. >> this amendment would strike the public health insurance option as established in section 142 as indonesia -- as envisioned in need bill. it would not save consumers

money. that does not uphold the spirit that the president set out to do health care reform. they all but omitted that in their revised estimate wednesday said that community health insurance option -- when they said the community health insurance option was not projected to have premiums lower than those charged by private insurer plans. what is the point? martin mcclellan noted this auction falls short even of what supporters had envisioned. -- noted this option fall short. they can get lower cost by exerting power of their plans don't have, or a can go the other way.

-- lower-cost by exerting power of their plans don't have. -- other plans don't have. it does not meet the spirits of the president's objective. the reason why proponents don't want to overreach is because they know american people are opposed to a government-run health insurance option. by a 60-31 margin, americans prefer receiving health coverage by private insurers, according to national polls. some may have noted a recent poll indicating wider support of the government option, but that poll was over sampled. i would suggest this is a confusing array of government controls for the sake of

government controls. i think i agree with my colleagues. we need health care reform. it is desperately required for our system to be revamped, but we will not be affected if we think the government can do it and do it better. this is not fair competition. if a referee is also a player in the game that is not about competition. i would urge my colleagues to vote for the amendment and strike the community health insurance often. -- straight the community health insurance option. >> i vigorously oppose the gentleman from north carolina's amendment striking the option to enroll in a public health insurance plan.

it erodes an important principle we're trying to establish, giving consumers more choice for affordable insurance. the public plans that we are advocating is very much in keeping with the principles that the president stated. the health insurance markets, this is what president obama said. the health insurance markets severely lacked competition and ask them to consolidate power over decisions best left to doctors and patients and have a big impact on costs. what the public option will do is provide stability by being in every market, provides insurers to move in and out of market changes, make sure that they have consistent providers. the public option definitely

promotes efficiency. the community health choice bill can achieve growth and fair competition, and also promotes innovation. our current health care system does not deliver value in the private market in the way our system is set up. it will promote it. the public option in the committee, and ordinarily i don't quote newspapers, but i bring to the attention the june 21 article by the "new york times" which calls for a public option. it calls for its because it talks about how we provide

competition, comprehensive coverage and creating a new paradigm that rewards a culture of wellness and prevention, and also promotes innovation in that area. i would hope the gentleman's amendment would be defeated and look forward to other senators who wish to comment. >> madam chairman. >> i just wanted to call attention to this chart we passed out this is taken from a study the american medical association did in 2008 called "competition and health insurance." it goes state-by-state and tries to talk about the market share of the two largest health plans in 2006. it makes the point that in north carolina, between 7% and 79% of

the market share. -- between 70% and 79% of the market share is shared between the two largest health plans. in my state is was between 50% and 69% of the market share that was controlled by two largest health plans. those state-by-state and the point which i take away from this is the additional competition in our health delivery system is important to promote. and i believe the public option is a way to provide that additional competition and give people an additional choices, as the chairwoman has said.

i would strongly oppose the amendment. >> thank you madame chair. i would like to have my voice in strong opposition to this amendment. i found it very interesting to see that poll which said 72% of votes nationwide would like to see a public option. recently up in oregon i have a town hall in a rural conservative part of the state. many people rose to speak about health care because of some concerns they heard. after a dozen folks had shared their opinion i took a poll of the 120 folks gathered. a handful said they would prefer to have a single option. about 15-20 raised their hands to say they would prefer to have only private health care options. the balance of 80 people raised

their hands to said they would like to have the full set of choices so that they could choose. i think this makes a lot of sense. in oregon, we have a public option in workers' compensation. two decades ago the business community was concerned about the dysfunction in the private insurance market and decided to create a public option in workers' compensation. the result has been an outstanding improvement in the insurance market for workers' compensation in the state of oregon. more efficiency, the competition has produced lower prices. it just kept everybody on their toes. we have these sorts of arrangements for about our society. we have a public option on mail that competes with private companies that deliver mail.

i really think that taking away and options from the citizens to choose a health care plan they think would be better for their family is a huge mistake. it will result in the same runway prices we have right now, the status quo is destroying our nation. we have cost increases per year of 10%. we even had a major insurer had a year over year increase of 26% followed by 14%. can you imagine the number of small businesses with this cost increase that are saying we cannot continue to provide insurance? another piece that is attractive to the public option is there are areas where private insurance companies are not good at doing. one is prevention and also

disease management. they may not have that person as a customer 10 years into the future, so as the public option is structured, there will be influenced by local boards that can provide guidance on how that would work in their particular state. i think that is a very valuable possibility as well, so that states that would like to see more done on prevention, maybe more done in terms of the structure of payments so we have more integrated health-care providers reduce the return rate to hospitals. let's not take away a fundamental opportunity for the citizen to choose the health care plan that best suits their family. >> madame chair. >> i would yield to the ranking member.

i appreciate that. thank you. what we are talking about here is you call it public option and i call it government-backed. i don't think one plan is the answer to more competition. one plan takes away choices. pretty quickly we would have one plant and not two. we see a% of the market stunned by two of the largest health plans, we would have -- we have 80% of the market owned by two of the largest health plans and then we would have just one. we all agreed that a lack of competition is the problem, but don't eliminate lack of competition by doing one company that can have dominance over every other company and put the rest of them out of business.

we have medicare partd. when we started to go into this we said there are only two people in wyoming produce pharmaceuticals. what will i do if wyoming winds up without a provider? one of these solutions was thrown out there was having a program that would be done by the government that would be a backup in case there were not two companies that provided the insurance. we provided a lot of incentives for people to do it and i never had to worry about that because 49 companies wanted the business in wyoming. we went fromtwo to 49. it brought down the prices by 37% before it started. it has been below ever since it started. every time i went around the state and i did a bunch of town hall meetings to get people to sign up for this.

if you don't sign up, then you start paying a penalty. i am pleased that my amin was one of the record states for a signing up, -- i am pleased that wyoming was one of the record states for signing up. their first question was how come i cannot get the drugs i want? how come i can i get the drugs my doctor is prescribing? the program had not started so i said i bet you are a veteran. they would say yes, how did you know? i said the veterans organization is a government-run operation that takes bids. the only way you can do bids on different medications is to say to the producers of the heart medicine that they have to bid against each other. the doctors will say those drugs do something differently. for my patients one of those is better than the other by one of

them ends up with a contract. that one medication is the one that the veterans can get. i had 1000 veterans change from the veteran program to medicare part d so they could get the prescription they wanted. kent conrad suggested a way to increase competition. he talked about co-ops. but he got the idea from the wyoming farmers union who thought that a health co-op would help them. i hope he will take a look at that. that is a way to have more competition in every and even r. that we are able to participate in. that is nationwide but different states have different requirements, so there is a

smoothing technique and the costs are kept down. it needs more fleshing out but it does remind me of a program that i brought up in the senate called small business health plans. the way that that competition worked was businesses could group -- they could group together through their association across state lines and even nationwide. they could get a big enough pool so they could effectively negotiate with their insurance company. ohio has one of the lowest costs. they have enough population that they are able to do these plans without going across state lines. what was the effect? the effect was 37% administration costs came down

to 12%. that is a pretty big saving for any business but especially for a small business. that is what they can achieve by grouping together. that bill came up with the -- it came up in the senate and it got 58 votes. we never got to mn for those, so we never got to solve the problem -- we never got to ammend for those. people were working on something similar for a long time called associated health plans. with this, those organizations could form like a big company does and use derisive rather than other requirements. there was a lot of opposition to that, so that never went anywhere. but the small business health plans has a lot of potential everywhere, a way to bring down

costs, a way to increase competition. you mentioned that in some of these states cannot 50% of the market is by the two largest health plans. i bet that a lot of times the largest part of the market share in any business is held by one or two companies. i would like to reverse that. i think small business is where it is at. i wonder with the general motors' problem what would have happened if we said back in november, we are not going to give you any money. i think we would have had a short-term catastrophe and a long-term solution with many car companies developing out of that. each one trying to find their own niche and competitively working. it would have been another

example of how competition can work. one plan is not the answer to this. we are not adding options, we are taking away our options with a government plan. >> that was debate from a senate health committee. the amendment failed 10-13. shailagh murray, that we heard the senator talk about analysis by the congressional budget office on the public plan. he said it showed implementing that public option would not result in cost savings. >> that is probably the best republican argument against the public plan, that is difficult to illustrate under the terms congress relies on, which is the 10 year window that whoever is trying to pass a bill of this scope is always unhappy because

it never takes into account the variables. the democrats' argument is that a public plan would change the behavior of the insurance industry which would lower health-care costs in the long run and create less costs were the government through medicare and medicaid, and save businesses money and leave it to this economic tipping point, but it is hard to illustrate that. so what republicans are saying is this is a huge risk. we are taking the government further into the health-care business, yet we are not getting anything obvious back. >> just in recent days there was some talk about the cbo looking beyond 10 years and looking 25 years out. is that going to go anywhere? >> i think a large number of

senators in particular pay close attention to these issues, a lot of conservative republicans are just as focused on the deficit and getting government spending costs under control, but they cannot figure out how to change the system without making it look like they are trying to change it to benefit it for themselves, in this case to pass this bill. and some of the policy risks involved in it, too. there is a credible argument to be made that it is so all encompassing that you cannot take a traditional look at it, but they can agree on a non- traditional way of looking at the budget numbers. >> one idea reheard and a lot more about is cooperatives.

what our health care cooperatives? >> those would be modeled on the way that world electricity providers are organized, or the way telephone service used to be provided where you have lack of competition in a marketplace. consumers band together and provide a not-for-profit format service to themselves. these cooperatives would function that way like the bluecross blueshield model originally. that is how that company came into being. that is kind of what the supporters of cooperatives have in mind, but critics say the democrats who prefer the public plan say aren't cooperatives just as big of a risk? the government would be

responsible for these. >> there are democrats who are supporting co-ops, correct? >> that is the finance committee bill that is likely to create a cooperative model as opposed to a public plan, because finance committee members are more conservative and don't like the public plan. >> the public plan was subject to a number of amendments. another was cer. tell us about that. >> that is one of the provisions that scares people because one of the problems with the health care world is that it is an ad hoc. the type of service you get and how a disease is treated depends on what hospital and you end up at 81 part of the country -- and

was part of the country you are in. people have come to rely on that. they have come to see that as choice, and that is a reason the u.s. health-care system is so great and offers such great service, but it is also what is costing the system so much and leading to a lot of deaths and medical mistakes, and is partly what fuels the malpractice problems. competitive -- compared it affected this is a way to look at -- the comparative effectiveness is a way to look at procedures to see what works best and impose those procedures broadly. disease management is the big bowl -- the big goal is to find

ways to manage diseases like diabetes and heart diseases. >> it is not something new. it is happening now. >> exactly, and everyone in the health-care industry wants to become more efficient and safer and make people healthier. >> is this the issue republicans are focusing on and saying this is rationing health care? >> right, and it will take options away from you. if you want to have a c-section , that ought to be your right, even though statistically that is not the best option for you. there is a sense that -- we have a sense that we have all the options in front of us but not all of them are from us. >> which uses this cer the most?

>> the idea would be it would work from the grass roots up. doctors and providers would start to make decisions based on this, and insurance companies, at their policies would reflect those decisions. >> there is 25 minutes of debate from the senate health committee on comparative effectiveness research. >> some of the conversations we have had especially during the round table was the fact that the cer section was to provide research that did not necessarily mandate standards or deny care. if you go to section1-13 -- section 10-13 which passed with bipartisan support, there should not be any reason to oppose this amendment.

what this amendment is designed to do was to not allow somebody besides you and your physician to decide what your care will be. as senator mikulski has correctly noted, i can give you 1 million examples why cer will not work. if we think it will work for any other reason other than to ultimately practice medicine at the federal government or use it as a tool to ration, one of the ways to secure that it will not do that is to adopt this amendment and embraced what happened in 2003 in the medicare modernization act. what this amendment would require that the director for the center of comparative of effectiveness research shall not mandate any quality health standards.

it does not mean they cannot study or recommend, but it means they will not mandate. the reason that is important is a question i raised when we were having a conversation, because if you mandate it and my patient should not be treated that way, you have created a liability for me that will be impossible for me to defend in a court of law because the government says this is the way you treat patients, not what my clinical experience says. it also prohibits cms from making any coverage decisions. that is the current law. it shall include a reference to the prohibition in any recommendations resulting from projects published by the director and any communication activities performed must reflect the principle that

doctors and providers should have the best available evidence upon which to make choices in healthcare. services, drugs, treatments, devices. it is the research must recognize that patient preferences may vary. all given the same outcome. if we have the assurance this is not meant to ration care and our purpose in doing this is to find out what we think is best most of the time for the average patient, and we want to put that out, then fine. but if we're going to tell doctors what they will do and patients what they will do, it is not fine. because it is not based on the best care, it is the best based on cost as well as outcome. without this amendment i would

like to know what section of the bill prohibits the government from using cer to decide what treatment the patient can and cannot have. what section prohibits the government from developing rationing methodologies like they use in england? i trust that your intent is good, but where is the protection? i will go back and remind the of that today medicare -- i will remind you that a medicare patient today cannot have a virtual colonoscopy per orders of the dictate of cms. cms has decided that is too expensive for the benefits that we get, so no medicare patient can have it. we are already starting to see

inside cms the utilization based on cost data but not necessarily outcome data because things cost too much. the data on costs compared effectiveness is clear. all you have to do is look at cancer survival rates. all you have to do is look at lifetime -- the first coronary artery and then. it is clear. i am happy to have cer in there if we have protections that says we will not have a bureaucrat telling a patient what they can and cannot have. i am not against good practice guidelines. i think we ought to do everything we can. but a mandate is a totally different thing. when we mandate it, what we do is we say medicine has checked

the box and we deny the fact that medicine is personal, that past medical history is pertinent, that a physical exam at the time of considering past medical history as well as the clinicians experienced with the patient, should have an overriding position as to what that patient decide. i don't think we have those protections in here and i think we ought to have them. we already have language that protect that, and on a bipartisan basis we agree to it. i suggest we expect this so we offer the assurance to the american people that they can true they have what is best for them as decided by then and there provider. >> you have amendment numbered

9, and some of the aspects of that that i like and others that give me great concern, but i will deal with the washington bureaucrats. like every time this discussion comes up about washington bureaucrats deciding, washington bureaucrats are not going to decide anything. they are going to publish reports. let's talk about who we are talking about when we talk in washington about who does research. washington bureaucrats are called nih. those washington bureaucrats are called fda. those washington bureaucrats are called the institute of medicine. i don't happen to think they are washington bureaucrats. i happen to believe they are very capable research people who

devote their life to trying to come up with evidence that would support the initiatives that would save lives and improve lives. could we get off of this washington bureaucrat stuff? >> the question is -- >> i am beginning to find it on their behalf, offensive. i represent people who work at the national institutes of health. i represent people who work in fda. they are doing their best to come up with those ideas that either will save lives or extend lives. you have given examples of cancer and virtual colonoscopy is. where do think that came from? that came out of a lot of government-sponsored research or government doing research so that the private sector could use it. when we talk about aren't we the

latest and greatest? we are in the top five of medical expenditures in the world but we are in the bottom 37 in terms of health outcomes. the whole idea of what is coming out of comparative effectiveness is to enable more evidence in the practice to -- evidence informed practice to occur. the people who are going to be providing a lot of this research will be coming from these iconic institutions in our country. they are iconic, that they are known around the world as incredible institutions. we are finding it convenient to turn to the institution of medicine to do a study, but when we are talking about comparative effectiveness we call them washington bureaucrats come out

like they are people -- washington bureaucrats, like they are people who are incompetent. i would like us to get off of that. the second thing is we continually say that in this legislation, and i have given chapter and verse that we do not mandate clinical practice. >> there is nothing that prohibits the mandate. there is no language that says we prohibit the mandate of this interfering between a doctor and patients decision. please name the section where you mandate that a prohibition that you will not have. >> go to page 323 and tell me where that says it is not construed as whether that is sufficient. then its says what you want to do in your and then it is safe

not mandate national standards of clinical practice. there is nothing in here that requires a mandate. quality health care standards could be any number of things. one of which could be the development that the effectiveness of various checklists like the famous one that you know and i know has improved outcomes surgical arenas and saved lives. i think michigan told us it saved $200 million. it is not the clinical practice that i worry about, it is the quality health care standards. >> may i ask you a question? >> i would like to finish because we could have enlisted questions. >> we need to have endless questions on this. >> what is it about quality health care standards?

you have said over and over, using the same arguments. let's go to the quality health standards. >> i want to read you the text. recognition shall not be construed as mandates. that is a big difference than saying they will not be used as mandates. bay i make a suggestion? -- may i make a suggestion? let me make my point. let me make my point for a minute. we are in medicare -- where in medicare law do we have the right to tell an 85-year-old woman that she cannot have a virtual colonoscopy? and yet that is exactly what we're doing. that is what is happening at cms

today. as the pressure builds on them as we get to 2017, we will see more of that. >> could we come back to quality health standards? >> sure. >> because i don't know what you object there in establishing a standard in quality health care. >> here is where i object. we decide that we convene people in washington from very iconic institutions. we set a standard and then we

will expect to put that out and now we will have a national standard for care that is going to be [unintelligible] not because it is mandated. because the -- if you go against the quality of care he will expose every physician who does not do it exactly that way, even though their patient should not have it done that way, to liability. all of a sudden we now say there is one white where to do this -- there is one right way to do this, and it still does regards the patient history, clinical history, experience of the physician and all those combined. >> according to the sections in

this bill where we talk about national quality standards, we're talking about patient safety, the reduction of medical errors and things that happened inadvertently. i sincerely disagree with you. what you do have been here that is good is to conduct research on the proven methods of disseminating information. i think that is good because we have to know how best we communicate this in a way that people could be broadly informed, but evidence informed and not the practice mandated. also, on the last 21 through 25 , we are back to prohibiting cms may not use data obtained in accordance with this action to

withhold treatment or prescription drug. i believe we have covered that. >> can you offer me a way where we can give providers protection if the art of medicine says at this instance i should not do what the government recommends? >> let's turn to the national academy to do that, because you know more about the practice of medicine. i know more about the administration. >> i am talking about in the legislation. >> throughout this legislation i have turned to the national academies for advice to be sure we do not interfere. i have great respect for clinicians and the responsibility they assume, and their training and dedication. if you're looking at how to do

that, i would like to ask them how they think is best done rather than a back and forth here. >> there may be exposure to physicians based on what we will do. >> based on what we did in the american recovery package and what we're doing here, i think we met that need. if other national academies of clinicians, whether they are pediatricians or cardiologists say we think we have a better way, i would be open to hearing it. right now i don't want to change what we have in the law based on a back and forth. there are also some other illegals wordings, but i think we need to look at that. >> mr. chairman? i will ask unanimous consent that on page 323 of the bill

line 5 where it says these should not be construed as mandates for payment coverage, that the word on line 6 be stricken and that the bill would -- the bill should not be used as mandates for treatment. i think that would satisfy a lot of the concern raised here. >> that is exactly the suggestion by senator harkin. >> i call that the harkin rule. >> i will be sure i know the consequences because words have meaning. i don't want -- i would like to reserve the right to object if we could -- >> could we leave this open as a possible suggestion? >> that is exactly right. >> the acting director of nih, not a washington bureaucrat, stated that cer would be used

to contain costs, as did very summers and kathleen sebelius. -- as did larry summers. >> if we can leave this open, that is great. >> i appreciate -- >> i withdraw my request under the circumstances. >> this is a very important section of this bill. medicine is personal. medicine is individual. it does not fit in a box. >> but it does fit practicing guidelines. national academies of clinicians -- >> can i finish my point? guidelines are important but they are just that, they are guidelines.

if in fact you pass this bill out here with this, you will raise the cost of medicine, because now what we will do is here is the guideline that you need to follow as sorted out and implemented. the people who will implement this will be bureaucrats. the first rule of the bureaucrat is never do what is best when you can do what is safe for your own job. that will be the logo under which they operate and administer whatever comes out of cer. and when we deny the fact that medicine is personal, that it is individual and guidelines are just guidelines, and we create a situation where physicians have another step in the process, here is the government guidelines so now i have to back up what i am doing with this other stuff because i know from my experience and what the patient is telling me that she

does not fit the guidelines. i will spend a bunch of money because i am not about to expose myself to a lawyer that will say you did not fire they -- you did not follow the guidelines. if we are trying to save money, you will actually increase the costs for everyone who doesn't fit guidelines. what is wrong with us saying we will not allow this to mandate the care and get in between a patient and a doctor? >> as i have been listening to this and senator mikulski has done the bulk of the work on this section, but unless i am missing something, i don't hear much of an argument here. maybe there is some language we will look at, but as senator roberts pointed out, if what senator mikulski has said repeatedly that it is page 323, and the word used would make it clear on that, then the debate

over. we are checking that out, but i don't think you are wrong at all. the question is does the language form to that goal? once it does i think we have answered the question. i think your point is taken. senator mikulski agrees with your point. the issue is whether this language -- i am asking if he knew something about the word i did not know and we did not get the answer to that. i hope that will solve this issue. >> it solved all the issue but the liability. >> that is different than this. >> the point is we are not going to fix the liability, so you will still increase the costs. >> the issue of guidelines exists, and i presume in every court of law were in action is brought against a provider, that

guidelines would be suggesting it you did not follow a guideline. i presume that is a course of action followed by a plan in any medical -- are you mandating something? i think we are all pretty clear that we are not because of the point you have made, but i presume some lawyer will make a case that guidelines have not been followed. . .

>> what congress is trying to do is to set forth in a system of grants and entities that will help to advance the developments of quality control measures and also the best practices that will effect the way all diseases are managed. people are focused on the end of life issues. the intent is to manage all kinds -- from the broken arm that shows up to the chronicle asthmatic -- to the chronic asthmatic child to cancers and heart diseases and the end of life issues that have attracted so much attention. >> of the private organizations?

>> the health committee bill would create a center for health outcomes research and evaluation within the government umbrella, under the government umbrella to conduct research on the effectiveness of health care procedures and provide information and a therapist. basically, pulling together all of this information and trying to make sense of it and get guidelines. people complain that they do not understand how the health care system works and they tried to ask the doctors and do not get straight answers. that has an effect on the economics of health care, as well. people are not able to control their situations as effectively

as they could or want to. this very complex title that has attracted so much attention is the goal. >> the next sec bring deals with the issue of requiring people -- the next section shows the issue of requiring people to buy health care. >> it would impose as would the house a bill and the senate finance committee, as well, would impose both an individual mandate requiring people to buy health care and there will be a penalty for people who did not have insurance. they see this as being administered through the tax code. it is not their jurisdiction. >> would anybody be exempt? >> all kinds of people would be exempt. if you were eligible for

medicaid, which would be expanded under this bill, you would be required to sign up for it. one of the big gaps in coverage right now are people who are eligible for government coverage, up 9 million or 10 million people, they're eligible and do not sign up for it. a lot of these folks are people with diseases and the sharp at emergency rooms and are costly uninsured individuals. trying to get people into the system is another goal. the individual mandate -- the goal would be to force them into the system. >> what about families? are the penalties different? >> yes. this is one of the most difficult issues that the finance committee is wrestling with and is probably -- it will

probably cloud this debate all the way down the line. what costs can you impose on people, middle class people who may be under insured or who do not have insurance and cannot qualify for government coverage but for homwhom and what have to pay more under these bills. to the health committee bill would provide a subsidy for people up to 400% of the federal poverty level. that is about $75,000 for a family of three. the gap between what the subsidy would cover and what a family would have to purchase in health insurance could considerably. several thousand dollars a year

in out of pocket costs that will be hard to find room for. that is an issue that this gang of six negotiating this and continues to go over again. >> here is what the health committee had to say about this amendment dealing with insurance. >> i would offer an amendment to 04, currently the legislation includes a requirement that all americans obtain coverage -- amendment 204, both the sec and the healthy buy coverage, -- both the sick and the healthy buy coverage. it is a major factor in expanding coverage. individuals who do not comply

are assessed a penalty, or that is what is proposed. currently, the penalty would be 50% of the cost for a family. such a penalty could be as much as $3,000 for an individual, up to perhaps $16,000 for a family each year. that penalty is too high in my view. the amendment i am offering would reduce the cost to a more reasonable level of $750 per individual or a family per year. it is my intention the penalty would be sufficient to incentivize most americans to get coverage with up creating an on fairly large penalty and an unfairly large financial burden.

creates parity between the payments that an employee would have to make if he failed to obtain coverage and is a payment made by employers, $750 per year insuring that shared responsibility and employees. it would improve the basic bill. i urge my colleagues to support the amendment. >>, i asked the senator a question? has cbo looked at this? >> i do not believe so. >> it is an ecological, if you reduce the penalty -- isn't it logical if you reduce the penalty and more than that for families, that people are going

to opt for the penalty rather than buy insurance? crest i think it is logical that some would. the number, i do not know. at least based on my interpretation of what's cbo has told us this morning, they believed that most americans would go ahead and obtain coverage. if there is a financial penalty for not doing so. the size of the penalty is a factor with some, but it is not the main factor. i think you would have some last compliance. i did not think it would be substantial. >> wouldn't the cost to the government go up significantly, too? those folks who opted to pay the penalty would theoretically not be paying, not be insured.

when they go to the hospital or one have an accident or contract a serious disease or marginal disease, those medical costs will probably end up be by the government specifically. you would wind up with more uninsured -- the $750 would not cost the medical -- it would not cover the medical costs. what their medical costs would be and their insurance costs. >> you say people who choose to pay the penalty and do not it coverage, they could then be running up the cost to the government. is that your argument? >> it should they incur in medical costs, somebody is going to have to pick it up. >> we have talked a lot this afternoon about cost shifting. the biggest cost shift that

exist is by folks who do not have any coverage. providing coverage to them and going to the private sector. the main thrust of this bill is to reduce the number of those who do not have coverage. you are right, there will be some who choose not to get coverage and instead pay the penalty. i think it would be a relatively small number. i think the advantage of reducing the financial burden on families and individuals far outweighs the downside of having some increase in the number of folks who choose not to obtain coverage. >> wouldn't you want the penalty to track with the cost of the insurance? because obviously to the extent the penalty is less than the

cost of insurance by a significant amount, you basically will be subsidizing those who opt out of insurance. >> i personally do not feel comfortable supporting a penalty that is a success -- that is as substantial as the cost of the insurance is. i think that is an undue burden on those americans and families and i would much prefer to have the penalty imposed on individuals at the same level as the penalty imposed on employers. >> i do think this type of limit has a fairly significant impact on two items. >> as i say, the amendment has not been scored. none of the amendments have been scored. this is one of those.

>> can i ask a question? i did not hear the whole thing. i am not sure i understand your amendment. what would be the penalty to a family? >> the penalty to a family would be $750 or for each individual who is required to obtain coverage. if a family is made up of a single spouse and a child, the spouse -- the adult would have to obtain coverage for that family or would pave the penalty of $750. >> my question is family and how you're defining family. you are defining it in terms of a cult members of a household. how are you defining a family? >> i am not changing the definition of a family in this amendment.

the family is defined in the bill and i am taking that definition. >> how is the family defined? are we defining family or members of a household. >> let me ask for clarification. >> there is no statutory definition for a family. the underlying text refers to family coverage. >> here is my question. in some ways, piggyback saw on the other senator's bill. two adults in some type of the union. i think it would be $3,000. is that correct? >> it is a percentage -- >> one under $15.

-- $115. >> could you clarify that? >> it would be a percentage of the applicable premiums. it is harder to define in hard and fast terms. it would depend on what the premium would big. it would be no less than 50% of that. >> what if you have an extended family and you have two adults and their adult daughters who might be living in the same household and they might be single. does everyone in that family and they might have children. the adults are aged 40. the daughters are age 40. they are living at home. all that is going to happen for

$750? >> livni clarify. any individual required to obtain coverage -- let me clarify. there would have to pay $750 penalty if they did not obtain coverage. if there is a child's that is not required to obtain individual coverage, the adults would also -- would still be obligated to obtain that coverage for the >> thank you. >> we said it covers -- it taxes too much and covers too few. if you change the mandate, i think it amounts to about $36 billion worth of revenue to cover the costs of the bill. any mandate is a new tax.

the majority of the uninsured or middle class and that is who would have to pay this tax. so i think that this is a way to lower those taxes. i do not know about the people who are covered. i am curious why you did not reduce the $750 down to a lower number as well. >> it seemed to me there was some value in having parity with what the individual was obligated to pay by way of panel say and what an employer elsewhere in the bill is required to pay for failing to obtain coverage for employees if the employer has more than 25 employees. >> mr. chairman? a question.

for roughly 2 million plus the federal employees, under the rules, when the dependent of a federal employee turns 22, on their 22nd birthday, they are no longer eligible to be on a federal workers' health insurance. in many cases, those kids are still in college. my question is this. for those 2 million federal workers, would their children when they are driven off the federal policy at age 22, would they then fall under this panel today that they had to have their own insurance? they still may be a dependable not eligible for their parents' insurance. >> senator, i think the

amendment clarify is this. you. not a reason why it might be simpler to go with a clear per capita assessment. the language as written would say that if there were a failure with respect to more than one individual in a household, the applicable penalty would be 50% under a basic plan, basic qualified health plan. that does raise a question of how do you find the family grouping packs there's not any federal definition of a family. this change would obviate the need for a kind of definition. >> so the dependent of a federal employee would be uninsured, would not be assessed a penalty for not having health care

coverage under that amendment. >> i do not believe so. the requirement to obtain coverage, a loss of the penalty for not obtaining coverage pedicures to every adult and to the extent that the adults is uninsured or does not have qualified coverage, then the penalty would apply to that individual subject to all of the exceptions. >> to further understand, the dependent of a federal employee would be responsible under the plan for a maximum of $750 fine per year if in fact they did not individual insurance for themselves even though their

parents had a federal health insurance and if we did not pass that plan, they would be exposed for a penalty of 50% of the premium of healthcare purchased. is there right? >> partially. under the hypothetical you described, the 22-year-old would be available -- it may not be a case for this. the 22-year-old would have available coverage if they did not have other options through the qualified health plans in the gateway. if for some reason they chose not to come up there would have a young adult plan option. if there were not covered under the other exceptions, they would be subject to the penalty. >> i think you.

if this was a pool of 2 million individuals, i would think the question would be insignificant. it covers an independent style as long as there in education up to the age 25. do you know? federal employees, opm sets the date whether they are in school or not at age 22. 25. there is a three year difference with those two million-plus federal workers who are faced with a totally different situation. a it reduces the cost of insurance for the federal government by zero. the premiums do not go down. your now loading the pool up with older, sicker people.

i do not want federal workers to get a double whammy if their children to not have access to health care and find they cannot access affordable health care. >> there is a provision that applies essentially to every other insurance products except that and there is interest in taking a look if the insurance reforms and applying them. this committee does not have jurisdiction over that. there was no way to include it. >> i think it is a great point that richard has always. we should raise that. this should be conformity. let me also -- i want to support the amendment. but think you have raised a good

point. we do not know if the amendments will be excepted or not. i think i will make the request. i would request of cbo to take that amendment and givecourt in terms of the bill. i think leaving it as is, the numbers would be high in terms of people's ability to pay. it would become tremendously costly. >> are you saying the bill is not, fair? >> it is a high number and an unrealistic number. we're talking about middle income and low income people. you end up with an assessment that may be high. i think it is good. all those who vote -- how do you want to do it? >> do it by voice.

>> all those in favor say aye. the ayes appeared to have it. i will make that request that senator gregg has raised. it is a good question. >> you have been watching some of the debate of health care legislation. shailagh murray of "the washington post" is with us. >> the senate health committee bill would impose a tax of up to $750 per individual who does not have health insurance. there are some exemptions for indigent folks and illegal immigrants would not be covered under these provisions. the house would impose a tax on

individuals as well. it would be 2.5% of modified adjusted gross income. it would allow the government to collect a lot more money from upper income people who are not insured, younger people, for instance who make a lot of money. >> we have talked about individual responsibility and family responsibility. what about the responsibility of employers? >> another difficult, a technical issue. the fundamental debate boils down to a question of, what is the best way to incentivize employers to provide more and better health coverage? the have had enormous, plenty discussions about where to cut off, whether it should be 25 people, up 50 people. who to include in this mandate.

the idea is to get as many people as possible into these employment-based insurance pools. it is the way it is organized. it would be best to maintain that system. there is a debate going on both in the house and the senate over how you do that. do you create rules that businesses must abide by otherwise they face penalties and taxes? the house would take more of that approach. the senate health bill would provide a whole range of incentives and the taxes -- >> but no penalties. >> penalties also. it is a link the provision. >> silly penalties would be for a -- how would that work?

>> yes. for businesses over a certain amount -- there are subsidies that would be provided based on the income of the employees from the government to help the employer provide the coverage. then there would be penalties if the employer did not provide the coverage. the finance committee light -- likes the carrot approach better where you incentivize employers to provide coverage. they cannot figure out how to do that. in the meantime, they are exploring this penalty where you would not interact with the employer unless the employer refuses to provide coverage, and the employees and upon government health care. if you're a company that has a lot of low wage workers and they

end up in medicaid or their children and up in a government health care coverage program, the employer would be penalized for that. it is called a free rider provision. so that is a very much of a live ball how that will be resolved. >> listed below and some of the debate on penalties for employers who do not provide health insurance. >> the amendment i am calling up which i will be calling up shortly talks about employer responsibility payment to this bill. the bill -- employers with 25 or fewer employees are exempt from the current responsibility

payments. businesses will pay the responsibility payments after you hire a 26 employer. -- a 26th employee. with this amendment, passage of this amendment, they will -- payments will begin with the 26th employ you. they will pay for the number of employees over the 26 exemption. if the company employs 27 employees, they will pay for those over 25. a number of my colleagues have concerns about these cliff of 25 employees. so i think this is a way the weekend have the operation while insuring employers are

providing coverage. i hope the committee can adopt this amendment. >> let me strongly endorse the amendment. i think it clarify this what i think we ought to be doing and that does not have a cliff or a penalty when you hired your 26th worker. you would have to pay 700th $50 per year for that 26th worker. you should not have to pay $19,500 per year when you hire the 16th worker. it is my belief that this is a very good amendment. >> senator mikulski, you were involved in this debate earlier. >> thank you. i think this goes closer to the

intense and i do believe that if we have left it as is, the incentive for the employer would have been very real, to never go past that 25. that is not good for the businesses. it is not a good message to be sending. i appreciate the efforts. we still need to have a little more information about what we had discussed earlier about what is the right number. is it 25, is a 50. it is a closer to 100? there is a sensitivity analysis on this. this small effort is certainly very helpful. >> thank you, senator. >> this could be used against this one. it is an improvement.

i have a question. this would be for david. we're not just excluding the first 25 people. this would be 25 people in all businesses. >> correct. if i read it, it would apply to the 26th and all subsequent employees. >> i was going to raise the same question. whether you employ 26 or 2600, the first 25 would be excluded. >> that is correct. if you had 26 employees, you would be paying the extra money with respect to one employee. >> one additional point. $52 billion. >> no, senator.

>> when did the change? >> i thought it was $15 billion. >> we got a cbo scores yesterday. no, we got one yesterday. >> i think senator murray may be right. >> it is only 15. >> is still $15 billion. you are still going to have fun trying to get the taxes raised in this country to pay for this bill. it will be increasing. the way we do cbo, we do not look beyond 10 years. >> i would respond that it did -- what did cost $52 billion was the amendment you offered. we are all offering amendments that we think the strike the right balance. the amendment i have offered the

strike the right balance to make sure we do not discourage employers from hiring a 26th employee. >> the $52 billion was $52 billion a did not want to collect in additional taxes with a deficit of $1.8 trillion. >> a good, clever argument for $52 billion. >> i am struck by how on the one hand we are criticized for putting too much burden on employers. it is attacked for being too expensive. >> i would be happy to answer that. we're coming from the viewpoint that we think it will not raise taxes on anyone. we think it can be done in a

better way with greater patient satisfaction with less cost to the american public, less burden on the economy, and still cover all of the goals president obama wanted to cover. we sent a letter last night. >> i look forward to seeing what that letter produces. >> we were doing well. let's keep moving. all those in favor of the murray amendment, say aye. the murray amendment is agreed to. >> what did they finally decide in terms of penalties cannot provide health insurance. >> they would have to pay an annual fee -- small businesses

would be exempted. small employers would receive a credit to provide coverage to their lower wage employees. so what the committee finally decided to do, it springs from the individual mandate. employers would be required for coverage and contribute at least 60% of the premium cost or pay $750 for each full-time employer and three and some $5 for each uninsured parton employer. -- for each part-time employee. there would be an incentive for employers who could not carry the burden themselves and a penalty. >> $375 for part time. this could lead employers to

just take the penalty rather than provide the coverage. >> four individuals, that would be the case, too. it would cost a lot more than that per year for a lot of individuals to buy health coverage depending on their situation, their age and what not. >> is that an incentive for businesses to drop the coverage? >> again, they think the incentive side of it will make it the much more appealing and it will become more of the norm for lower-wage employers to offer health coverage. more employers would simply offer coverage. by creating these exchanges and making an creating the health

committee calls them gateways. they're more commonly called these health insurance exchanges. people would have more options in the marketplace. there are not a lot of bareboned policies to choose from that provide things other than catastrophic care. one of the goals is to create more choices and better better suited for individuals, younger people with a lot of health problems. it would also be cheaper. they would be more inclined to buy the policy. >> we will show some of the debate from the committee on the expansion and the potential cost. we touched on medicaid briefly. cattell's what they're proposing. >> the health committee bill would expand medicaid to all individuals with incomes up to

$100,000. the house bill would only expand up to 133%. this provision is very costly. it is also very complex. medicaid is administered by states and through a matching program with the federal government. a lot of states have extended their medicaid programs to offer coverage to people at 1 under 50% or even higher in some cases. -- 150% or even higher in some cases. but for states who are going above and beyond and how to help states cannot afford to extend the coverage, the finance committee negotiators had a big conference call with a bunch of the governors before the rest -- before the recess. >> we have about 20 minutes of debate on the expansion of

medicaid. >> the amendment i would like to offer, and i will try to respect time is very simple. it says that if congress decides as a result of the work of this committee in this bill to expand medicaid eligibility in -- and to require states to increase what they paid physicians and hospitals who provide medicaid services, congress will pay for it. there will be no unfunded mandates. i would like to start -- amendment. i would like to start with a story. since my late friend said if i started with a story instead of making a speech, someone might actually listen to me. it is a good story. 1981, a long time ago, i was in

my third year as governor. i made the point to see president reagan by myself. i came to washington. i said, mr. president, i have a proposal. why don't we make a grand swap. why don't we -- you take all of medicaid -- that would be the federal government. and the states will take kindergarten through 12th grade. our reason was of thought washington's interference was removing our own responsibility for making it better. arisen for medicaid is after having been governor, i could see this but responsibility with the federal level paying 60% and the state level, 40%, was creating confusion, and elect responsibility, additional expenses, wasting money, and

fraud. i thought it would be better run as a single program. i think often back 28 years to if that had happened that states would be better off. every governor in virtually any state has struggled with finding a way to deal with the medicaid program. the cost has gone up. they have been partly dictated by mandates from washington. i considered waiver requests by governors that take a year. by a one-size-fits-all approach that results with a federal program that is being administered in the states. it is a source of enormous frustration. we just sent a letter to the national academy is asking them to look at the status of the

research universities. fe and other public institutions across the country -- they and other institutions are under stress because states do not have any money left to put into public higher education because they are spending all the money to keep up with the medicaid program. tuitions are rising. students and families are complaining. congress is upset. the medicaid program has been a source of problems. i go with this amendment to say that if congress in its wisdom as a result -- i notice it is a decision from the finance committee to begin with. it is impossible to look of this without having some understanding of where we will end up. if congress decides the best way

to provide health care to low- income americans is to put another 20 million people or so into medicaid and require states pay more money to doctors and hospitals, congress will pay the bill. this is especially important to understand because of financial conditions of the states. we have the unfinished of having a printing press. states have to balance budgets. states have small amounts of money these days. it was in 1936 before the federal government spent more than the states did as a whole. the federal government's used to be relatively small. in tennessee, the federal dollars that they spend is $19

billion. the state dollars are $11 billion. the states are becoming appendages of the government with the budget's been a large amount of federal dollars and smaller amount of state dollars. so we do something that affects state dollars, it has a dramatic affect. we will not appreciate what a big effect it is. we throw big numbers around. i have tried to give an example for two of that by asking governors, what would happen if we decided that the medicaid program should be expanded to 150% of federal poverty level. it has been talked about and it is assumed some times when the cbo rights us letter about the cost of the bill.

it has been assumed some times that we may require the states pay higher dollars to doctors and hospitals so that the medicaid program works. the medicaid program reimburses physicians and hospital at a much lower rate than the medicare program. medicare reimburses lower than that private programs. about 40% of doctors do not see medicaid programs -- patience for many things they want to be seen. maybe you could get up to 50%. it may be defensible to say that if you want to choose to put all of these low-income people into a medicaid program, which i object to, then we should make sure they have a doctor to see. otherwise, it is like saying here is a ticket to the bus, but

there is no bus. with this cost? governor barbour of mississippi said an expansion up like that would cost mississippi $300 million a year and have at least 300,000 people in medicare. in florida, they are having a difficult time meeting their population now. there are 2.6 million people. the amount of money, if increased, it would be $5 billion a year for south carolina. -- south carolina -- i mean, for florida. those are the state costs of the medicaid program. those are the ones i wanted to give to president reagan years

ago. they are about 40% generally speaking of the total cost. what does that mean in real dollars? i have tried to compute that. if tennessee had to come up with $1 billion or $1.2 billion in new dollars as costs shifted back to the states, that would be an amount equal to a 10% state income tax. we did not have that kind of money. tennessee is a very conservative state. i doubt if pennsylvania or for months or a georgia has anything like that kind of money -- or for monvermont or georgia has ag like that kind of money.

the federal government winds up paying for it. states do not find out that the have no money for community colleges and the haft have massive tax increases. that is the point of my amendment. i think this points out why the medicaid program is the wrong way to help low-income americans. it is poorly run. it is not accessible for many of the low-income people who need it. i think a better approach and one in which the taxpayer could well afford would be is what is represented by the burr bill or the gregg bill with the idiot that senator hatch have offered. -- or the bill that senator

hatch has offered. they can choose private health care of the kind that most of the rest of us have. it was pointed out that maybe it would cost more. maybe it does. maybe it does not. if the program is properly done. it does not add a penny to the deficit. it gives everyone an opportunity to be insured. medicaid, with all of its other problems, it wastes one out of every $10. $32 billion a year. that is a separate discussion. we have talked about this before. we have different views to some degree. i think medicare is a better alternative. congress chooses to expend its then congress should pay for it.

>> mr. chairman, i would have to oppose the amendment strictly on the ground that it is not really germane to the bill before us. this is a finance committee issue. the amendment makes an effort to deal with two problems. one is mandated expansion of medicaid. the other is mandated increase in provided payment rates. we are not mandating either one of them. this is something that senator enzi set, under hashed or any other republican -- senator hatch, it would be entirely inappropriate amendment at that time. but this amendment here, to have

this committee go on record trying to dictate what happens with medicaid payments i think would be a big mistake. i would oppose it on those grounds. >> technically, my friend from new mexico has a point. we are in an unusual situation. we work for the united states senate. we're taking a big subject and splitting it up and saying, you work on some of it and you work on some of but in one committee. we each have our responsibility for the hall. i have a copy of the bill we are working on. it is marked with collars all of the provisions of the bill -- is marked with colors all of the provisions of the bill. this is part of what we're

trying to do here. we're trying to look at health care as a whole. it is the position of those who wrote the bill that the way to deal with the people who can help themselves the least in this country is to expand the medicaid program and to make it worked as we have said, you are almost obligated one way or the other to make sure that the doctors and hospitals are there for people that you put in the program. how can we finished a bill here that in visions solving the problem -- that's envisions selling the problem without taking into account the principle that if we do that, we ought to pay for it. it is not our job to say how to pay for it. but we should have some idea of

what it costs. unless we say we understand, this is our strategy and our vision. but we are not -- we do not believe this should be dumped on the states. i think we have an obligation to take a position on whether we should pay for it or states should pay for it and leave for the finance committee how to pay for. otherwise, we should go back to the bill and review all of the provisions that might have something to do with another committee. >> i want to go back to your story the you open your remarks with. what did while reagan do? >> he liked it. there are just too many people in washington that disagree with him. the chairman or ranking member

of this committee actually introduced legislation which proposed such a grand swap. the idea was that k-12 would come to the states and that medicaid would come here. i actually think it would be the right thing to do today. there is some programs, the americans with disabilities and others, which are separate. the basic medicate responsibility, which is what we do for low-income americans, i think we should legislate it, we should figure out a way to do it, and we should pay for it. it could be part of the single payer system. or if through medicaid, we need to say that we pay for the increased doctors and hospitals so that it works. are we do it the other way and we give people money and let them go buy private insurance.

we cannot ignore it. >> i will leave this open for longer. we will not ignore the issue. we're not the only act in town on this health care debate. finance committee has an important role. there is some overlap. those who serve on the finance committee are correct. this is a fundamental question. i am not arguing with you about the numbers and the impact. this is clearly an issue we will have to address, particularly as you increased the number of people. we cannot complete this process, in my view, without addressing the issue. is it a matter for this committee to address?

i am willing to accept the notion that this is a matter that needs to be addressed. i do not have any objection to that. it goes to the heart of the role of the finance committee. they are wrestling with it at this very issue. how to pay for it? it is not an enviable task. i'm not disagreeing with the points you're making. we will confront this. one way or another. it has to be a part of this debate and discussion. i think we have these other matters that we must address if we're going to move forward. this goes beyond the pale in terms of overlap of jurisdiction. >> are we not going to agree

with how to reduce the number of insured? your letter in your new proposal said we will dramatically increased the number of insured. the way we will do that is we will pumping a lot more low- income people into the medicaid program where doctors will not even see them. then you're saying we're going in the right direction. getting costs under 61 $11 billion. or whatever it is. $500 billion on the table. it is floating around there somewhere. >> we talked about the issues. our bill combined with the work being done by our colleagues in finance -- we're not doing work of the finance committee.

we used a number. >> it is not floating over there either. >> whatever it is, we have to deal with it. cbo has to score what we do. we will have a lot to do. our job here is to write our legislation, score our bill, which i am consistent we do before we actually vote on number so we have those numbers. .

some of these initiatives are targeted. >> so it is fair to say the health committee takes on medicaid to send a message to the senate finance committee on how they would like to see the finance committee? >> you have former gov. lamar alexander concern about the effect on their state and wanting to express themselves on the issue. the buy-in has to be

considerable to pull this off. right now you have states across the country struggling with enormous budget problems. they cannot afford medicaid roles as they stand today. some of them see this as a major imposition, essentially. >> taxes are another area of the jurisdiction of the finance committee. what is under consideration in that regard? >> the most likely source of revenue on the senate side is a tax on very knowledgeable health care -- i'm sorry, health insurance plans. most people have no idea what the value of their health insurance plan is. many high-income workers and union workers get very generous benefits that sort of flow through the system without being taxed. but they are not taxed as income.

ideally, as conservatives would like to start taxing those conservatives because it is a major loophole on the system. the largest in the tax system. but that is not going to ever happen because so many union workers, lower income people, benefit from that, sort of like the mortgage deduction. i think they seem to be finding some compromise position where very large package is worth over $25,000 a year, that the policies themselves would be taxed on the insurance companies. so insurance companies would be discouraged from even offering policies. so the overall objective of getting people to think about how they are using health care, using it more efficient bank, ultimately, using less of it. >> the next clip we will show is

a debate among -- on defensive medicine. what is that? >> that is what many people believe doctors and hospitals practice in order to avoid lawsuits. many states have capped medical malpractice awards and have started to crack down on this issue which has created a lot of doctor shortages in the country, apparently. at least that is the strong conviction of advocate for small progress -- malpractice tort reform. if, hypothetically president obama were to concede some language on that issue, it could be received positively by republicans, but now is not the time to start giving that stuff away. >> we will be hearing from orrin

hatch in an amendment that he proposes. this is something that he proposes on medical liability. >> this is designed to improve access to health care providers and increasing assets -- access by reducing the liability system that is placed on primary-care physicians and underserved communities. what this amendment does is it improves access to health care services and provides improved medical care in underserved communities, rural communities, and especially among primary- care physicians. what this amendment does is it takes on the medical liability issue directly. let's be honest about it. as someone who used to defend

cases on behalf of doctors, nurses, health care providers, i have to admit, once they change the law from the standard of practice in the community -- if that's occurred, then they would be an assault from liability. they changed that law, mainly grew personal injury lawyers, to where it became the doctrine of informed consent. from that point on, every case with the slightest evidence goes to jury. even if the evidence is faulty. in the process, we have had an upswing in medical liability cases throughout the country that have been devastating to the health-care industry and especially to obstetricians and gynecologists, especially in

rural areas. if there is a bad result, even if there was no negligence or fall on the part of the health- care provider, what ever that brodeur may be. you can have a runaway jury verdicts that basically run up costs for everyone. consequently, a lot of obstetricians and gynecologists -- i'm centering on that because we just passed an amendment try to take care of women's problems. we have had a lot of obstetricians and gynecologists quit their practice. in some areas of the country, they are not only woefully deficient, women have to travel miles and miles to get health care treatment when they are in the process of delivering a baby or having other difficulties

during pregnancy. what this amendment would do is alleviate some of those problems because this is aimed at eliminating needless litigation costs in our healthcare system. let me go into that a bit. when the doctrine of informed consent became the rule, that meant that there was no way any doctor could fully inform the patient of all the problems that could possibly happen. you have to go to medical school to learn how to do that. even then, they would say that you have not met the standard. we have a doctor in pittsburgh where i practiced law, who would testify against any doctor, no matter what. he would make a case against the doctor and the case would go to the jury, even though they were, in my mind, frivolous, and often

fraudulent. that has been rector of -- replicated throughout the country. in the process, we told doctors that they have to make sure you have to do everything you possibly can and have every possible procedure in your history of that patient, so if you are sued, however frivolous, that you can say, i went way beyond the standard of care in the community. i have done everything i possibly could. i have used every procedure, medical device, etc. and in the process, even that would not fully protect you and the doctors, but at least you would have an argument in court that you did everything that a great doctor would do under the circumstances. hopefully, the jurors will understand there are cases where

there were bad results but no negligence and there should not be a jury verdict inthis. i have to say, this is what i call unnecessary defensive medicine. having said that, all of us would like to have necessary defensive medicine. in other words, doctors doing the necessary procedures, approaches that are minimum to making sure they have ruled out certain possibilities that could hurt you. today, and they go way beyond that. secondly, we know there are other utilization, capstans, mri's. these are important devices in the cannot do without them, but they are sometimes over utilized. one reason is because of potential medical liability.

there are other reasons, too. the fact of the matter is, most of these doctors are trying to build that history, that record. if someone has a bad result, they can at least argued was not because they failed to do something that should have been done. in the process, i said 30 years ago when i believed all necessary information -- when i believe that there was all this on necessary information, if i recall, they agreed. the american medical association acknowledged there was about $60 billion. they knew it and i knew it. today, it was far more than that. we have become so dependent on unnecessary defensive medicine

that the costs have skyrocketed. when this particular amendment would do is impose limits on non-economic damages that can be awarded in suits against primary care physicians in rural and underserved areas. they would -- this amendment would limit plaintiffs' ability for the same model of occurrence. finally, there would raise the standard for the amount of punitive damages in suits against doctors and facilities particularly vulnerable to the cost associated with not practice litigation. i'm the first to say that there is negligence from time -- time to time in the medical field and there are legitimate cases that are brought. certain cases have to be settled for a certain amount of money, but that have to be done.

so there are legitimate medical liability cases, but there are about majority brought to the defense, that are somewhere around $25,000 on average, and if the attorney takes that cost, they will take 30% of that. if the cases are legitimate, i do not have a problem with that, but that would amount to a lot of cost to society. this amendment may not be everything i would do. if i had my way, i would establish health courts to establish these problems in a fair and reasonable manner. if we can do it, which would be non-jury help courts, i do not know if we could do it, but at least we could move in the direction. secondly, there might be other pressure point ready to determine if doctors were negligent or not, without

having to indoor runaway jury verdicts. -- endure a runaway jury verdicts. basically it puts emphasis on non-economic damages, which is important, and it would limit total non-economic damages to $75,000. if you have tinted damages, it would be twice the economic damages. but it would have unlimited economic damages. in other words, no matter the cost, you would be able to cover them, including the non-economic damages. i have said before, this is where we are right now. i believe this is the right thing to do if we want to get health care costs under control. wherever they have done this type of legislation, they have

had much greater success in getting health care costs under control and limiting the explosion of litigation that has occurred in our country. states that have done this have benefited. frankly, i think it would resuscitate the ability of communities, rural communities, to get more obstetrician gynecologist to help women with the problem that they have to go through. personally, i think it is something we really need to do. i would be open to better idea is if someone has them but i think we need to set an example here since we have to bring costs under control. i intend that unnecessary defensive medicine is leading our country alive. frankly, i do not blame the

doctors were trying to bill austin their histories, their medical histories of the patients so that they can try to detect themselves if they are ever taken to court. hand that is happening, and i do not think anyone can rebut that. compared to when i was practicing law, i have to admit there were all lot of insurance companies who would insure for medical liability purposes, but not anymore. i know is an unpleasant subject and those who are devoted to american dollars -- i am

devoted to them on the right, does not this issue. the fact of the matter is, the sooner we can get litigation control, the better. >> first, let me express from my very great respect and affection for the distinguished senator from utah who has obviously been an extremely distinguished member of this body. before that, not just a leader of legal community in utah, but a nationally recognized lawyer of great stature. so it is with some reservation that i regretfully must disagree with him on this amendment. it concerns me that the insurance industry will so willingly turned its guns on the most severely injured victims of

the catastrophic medical error. the cost of liability insurance in the medical arena is the set -- comprised of medical expenses, investment income. it is comprised of plan experience. and it is also comprised by the cost of individual claims. in dealing with all of this, the one place the insurance company chooses to turn its guns is on high claims. high claims which are experienced by the people who suffer the most devastating injuries. a couple who have to come home with a damaged infant, which has completely changed their lives. for the rest of their life they will be carrying a burden of care. their dreams for that child are

changed. their lives are turned upside down by it. it is on them. the person who comes home severely disfigured and disabled by a medical error that there damages exceed half a million dollars, that is the person that has to bear the burden under this theory of insurance reform. take a look at the investment income. many people believe that it involves process is more than claims, but look at the experience part of it. it is now admitted, established by the institute of medicine that 100,000 americans are killed every year by avoidable medical errors. and that we will tap of the iceberg is part of a much

larger iceberg of medical care that is not legal. if it is 100,000 killed by medical errors, god knows how big the number is of people who are injured, left in the hospital, coming home with one leg instead of the other one. maybe they got the wrong one taken off. for all of that injury, i think this bill and particularly the effort led by the senator from maryland, our chairman, barbara mikulski, on quality reform, will actually do a great deal to reduce the body count, to reduce the butcher's bill from ever in american medicine. i hope we can focus on that because that is the humane and intelligent way to deal with this problem, the cost of medical error. it is to have less medical

error, not take away the rights of the people who are the most injured by that medical error. i think we find some support in this from cbo, just yesterday. i believe it was just a day. it has been a blur of health care for a while. i sat next to doug elmendorf from cbo and he was asked by distinguished members of the committee where the savings would be from tort reform, an insurance reform, in an amendment like this, and he said, no, it is very small. negligible savings, and you really cannot pick up defensive medicine because there are so many reasons for there to be. that distinction cannot be drawn for innumerable reasons, from good ones too bad ones like

having a friend with an ownership interest in an imaging clinic where you want to keep sending people. there is a lot of defensive medicine practiced, and not all that is a bad thing. some of the key to america healthy and this type of legislation simply cannot be documented to save significant funds, at least according to cbo. the last point i want to make is they always try to hit at the jury system and we all know that the jury system can be disruptive and uncomfortable. but under our constitution, it is supposed to be. it is often the last refuge of the individual when they are badly injured, when the forces of society are against them, when money for interest control of the executive. the founding fathers were keenly aware of the vulnerability of

governors and legislative assemblies to both corruption and passing passion. what they trusted to remedy that was that we could get before a jury of our appears to have our problems heard. to have the insurance industry now coming forward to disabled piece by piece that fundamental constitutional prerogative of americans, implied through the 14th amendment, i think it is just wrong. it is something we need to guard against. i would urge my colleagues to vote against this amendment. >> a portion of the debate from orrin hatch on medical liability in rural and underserved areas. it eventually failed in a party- line vote. shailagh murray is our guest as we go through the debate. they tried a number of times to pass amendments dealing with medical liability and it has

been a discussion in health care for a number of years. as it stands now, are there provisions in the senate health bill or on the house side to deal with it? >> certainly not to the extent that republicans want and would become attractive to them, possibly convert them. this is an issue where it is not worth giving a little bit away because you will not get anything until you give a little away. if you are going to deal on the issue, you have to yield some significant support on the republican side because it is too much of a broader political issue. >> any likelihood it will be taken up by the senate finance committee as the final piece of their bill? >> it has not gotten a lot of attention by the finance committee. they have focused on the medicare provisions up to this

point, but certainly as this debate unfolds in the senate, it is conceivable it could go in a lot of different directions. it could go sharply partisan and democrats could try with their barely 60-vote majority to pass a bill on their own. as soon as they turn in that direction and try that, they will discover factions within their own party that raise almost the same issues they are dealing with now with these republicans they are trying to convert. if that does not lead them across the finish line, then they are going to have to find a way to go back to republicans and bring them to the table, a few of them to the table, at least.

that could force some policy compromises that liberals would not be happy with, but that could be the only way to a successful conclusion to this debate. that is probably more likely route, but it is just not clear. we will have to see what the collective frame of mind is when we return. >> the next piece we will show his with giving grants to state to set up single payer systems. >> the single payer system is the goal for many on the left and will likely not be advanced by this bill. is an interesting issue. we were just discussing earlier, there had been little republican resistance to these medicaid

expansions. there was concern about how it would flow down to state, but most people believed the need to start filling in gaps with medicaid, and insure adults with children, and what not. and these programs are already in existence and they certainly do not function perfectly. they provide care that no one in the private sector presumably would. government would have to subsidize it at the least. many people on the left believe that this bill should ultimately move the country to a single payer system, but that just seems to be working against gravity at this point. >> we talked about a public auction, now we are hearing single payer. what is the difference? >> single payer is the government acting like a national insurance company,

providing -- you know, it depends on how you would do if. but the way that it operates in other countries where there is a national health care system and people are taxed or the money is collected town hall from the government and then it flows through the system that way. there are arguments in favor of it on a cost basis, that it would be more efficient way to deliver health care, but again, look at the political difficulties they have run into with just some of the pilot programs, looking at comparative research. he would have to impose that on a broad scale to make the system worked. >> one of those in favor of the system is bernie sanders. here is 10 minutes of the debate where he argued single payer. >> what i am introducing today is not a national single payer

system. i will do that on the floor of the senate. when it is is an opportunity to allow those states, who on their own want to go forward, to do something. this is what the amendment would do. it would provide planning grants for five states a year whose grants would be up to $4.5 million to be used for 30 months to develop a state wide single payer system. that is the maximum. ifwant to do it, they do not have to. what happens if a state chooses to go forward up to two each year? there would then be awarded implementation grants to carry out the plan. plans must approve state approval, commitments and the state would each receive a grant worth the aggregate of the subsidies that would have been paid on behalf of participants

in a way had the state not implemented bed demonstration project. in other words, we are not putting more money into it. what ever they would have received if they had not gone single payer -- that amount of federal money will go to the states to be used to single payer. not anymore. the states are implementing a single payer in would be able to request a waiver. these include the risks to medicare, medicaid, and health insurance programs. person to move -- well, etc. that is basically what this plan is about. i used to be a mayor of the city, and i am actually a strong, strong believer in the

concept of using state entities as laboratories of democracy. we have all seen it. a city or town comes up with a great idea, and mike wildfire, it goes around the country. i think we should allow those states that one too -- and i cannot tell you how many will want to -- but we should allow them to go forward. if it does not work, we will have learned something, if not, we will have learned something as well. from a conservative point, those who believe in local rights, this program makes sense. mr. chairman, that is the amendment. i would ask for the support of my colleagues. >> depending on the outcome, we appreciate your knowledge and input. thank you for that. any comments that people would like to make?

>> let me first commend senator standard -- sanders for his passion and focus on the issue. i agree with him and many of his criticisms on and we currently have in terms of the health delivery system in the country. i am not able to support the amendment, and let me give two reasons why. one is a general reason. i think this exercise, as i understand it, that we have been going through these days and weeks, is an effort to essentially improve the current health care delivery system we have in the country. fix the problems in the health insurance markets, provide additional subsidies for folks who need coverage but cannot get it. some of the ways, the coverage,

keep down cost and build on what we already have. this amendment goes a different way. this amendment would start us down the road of replacing the current system and had we decided that that was the right way to go, maybe it would make sense to consider this amendment since we are not proceeding to do that -- this amendment. since we are not planning to do that, i would have problems with the implementation provision on page 6. it calls for states may request and the secretary shall grant the falling waivers of requirements. to the extent necessary to carry out state plans. when you start looking at those waivers, that the secretary

would be required to grant, if requested, they would of course include a waiver of arisa as well as a waiver so that all medicare funds provided under title 18 of social security for beneficiaries residing in a state be allowed to be used for this. that all funds provided for medicaid for people living in a state be allowed to be used for this forfor chip funds to be able to be used for this. to purchase -- not otherwise be available to purchase for federal employees and retirees in the state made available. and then the other federal

funds that the state might identify and want to use. i assume that could include indian health care funding. try care, i do not know what else. there are a lot of people in my state who very much value those programs. i know we have had a lot of discussion and debate about how medicaid is a flawed program. held various of the other programs are flawed. i can tell you, there are many people in my state to appreciate those programs and i think they would be upset that often that their ability to obtain their health care coverage through those programs would be put at risk by a state requesting an implementation grant and asking to take the fund that would otherwise be available through those programs for them and pool that for use in this kind of a

single payer experiment. >> could i respond briefly? >> i think senator bingaman raises an important point. essentially what you are worried about is if someone is on medicare, medicaid, schip, they might see a deterioration in the quality of the benefits they have. in this bill, we are specific. individuals who would otherwise have received healthcare through any waived program would be guaranteed benefits at least as generous as those offered under the federal program. you raise a legitimate concern that the bill addresses it. >> i think the concern would be that this would insert into our current system of healthcare delivery very substantial instability and ups -- and

uncertainty. i am aware of that provision that you cited but i think there are people in my state, for example receiving their coverage through medicare who would not want to trust to the good offices of the secretary that all of this will be taken care of. they just assume keep the care you have through medicare and people on the federal employment health benefit program as well and various others. for those reasons, i could not support the amendment. >> further debate or discussion on this amendment? let me say, bernie, as well, you made a lot of comments that we can agree with. the reason we are around this table are for the reason that you have identified. the system is broken. it is in desperate need of repair the way it is.

so i do not have any quarrel whatsoever on your comments about that. i also have no quarrel with your comments on financing of campaigns. many of us have supported that for years and decades. it is pernicious and dangerous in my view. whether it is about this issue or others as well, they are equally as important. as jeff started out, the idea was the understanding that a substantial number of people in our country are presently lacking the coverage they have, and therefore want to know that we will not necessarily try to undo that, which we support, but rather to fix that which is broken. a substantial part of it is broken. there is a legitimate constituency in the country that embraces exactly what you are asking. that opportunity, as things

emerge and moved in time, will move in direction -- in that direction. but i would be reluctant to take this, which would to plan everything else we're trying to do, and i realize that is not what you are suggesting, but that is the danger that i would see in the adoption of the amendment, and therefore and am planning to oppose the amendment. >> thank you, mr. care. i want to applaud the senator from vermont for bringing forward a creative concept that is to utilize the state laboratory as a way to experiment with the single payer plan. when the state of oregon was immersed in treating the oregon health plan, they apply for federal waivers that were not granted or in some cases only granted after long delay. it is difficult for the state to experiment and the senator has

laid out a framework that i am sure will cultivate a very intense debate within any given state because it would take a statutory action by the state, as i understand it, in order to proceed down this path. that sort of debate about designing a different type of health care system i think would be healthy for the democracy as a whole. it would give us an example of an experiment that we could all learn from, both in the works and what does not work. we are certainly the beneficiaries of what has been taking place at the state level in oregon and elsewhere. this simply allows a far more flexible latitude in terms of the content -- design of a state experiment. so i certainly support the amendment and thank the senator for bringing it forward. >> you are watching debate from bernie sanders of vermont giving

state grants to study setting up some of their systems. it failed 4-19. it was a lopsided vote in the senate health committee. we are talking a bit about this. what does that say about the likelihood of the debate, single payer getting any attraction in the house? >> i think it speaks for itself. health care is always an interesting challenge because it is such an emotional issue. people have very deeply held views about what would work best. some conservatives feel just as fervently that you could create these health savings account systems where people would be paying a lot of their own health care costs, that people would

use health care more efficiently. so this debate, among many other things, it is an opportunity for people to express -- in the case of tom harkin, bernie sanders, it has been their life passion to try to change health care to adapt better, according to how they see it. a lot of what we saw in the town hall meetings, i guess, were the passions that are stoked by those strong positions on either side. threading a needle on the policy front through that sea of warring factions is just extraordinarily difficult. >> we are focusing on the senate health committee who is focusing on the single payer, public

option, and the discussion of health care cooperatives. do any of these ideas -- is any one of them gaining traction or scenes more favored by some as it moves through the senate? >> what people seem to be galvanizing around now -- and this is very early, but people, i think on both sides agree that there needs to be a reconstitution of the national insurance industry. a lot of the extremely popular provisions from all of these bills out there would stop insurers from denying coverage based on pre-existing conditions, would lift lifetime

caps on insurance. all kinds of barriers to coverage that people confront on a regular basis. regular folks trying to ensure their families, but they are not able to based on these barriers. there seems to be consensus forming around the idea of creating some alternative, possibly only on a catastrophic level, for instance, that the government would may be set forth catastrophic policies that everybody would have access to. for instance, with individual mandates, but it would apply to, instead of forcing people to buy more coverage than they may need before the age of 30. at least it would get them into the system with a bare minimum policy. some believe you can water down the public option by subcontracting it to a private insurance company, like kaiser, for instance.

that it would be administered by a brand name insurer that everyone would know and feel comfortable with. >> is that done in any other country that you know of? >> no, because there is not the well-fertilized private insurance sector that we have to. you have a large insurance companies here that could be capable of administering a program like that. at one point does it ceased to be a public option and just becomes a national insurance policy? the good news for dealmakers is, as they come back to washington, very few of the ideas on the table at the beginning of august are off the table. only the death panel idea has been probably effectively eliminated, even as hyperbolic

as there was. there probably will not be any final language in the bill that sets for end of life procedures. otherwise, all these issues are still there and left pretty much where they were one month ago. it is up to these dealmakers in the health committee, finance committee, and house, to navigate through this. >> we are going to look at about 10 more minutes of debate. then we will be back with shailagh murray. >> this is straight forward. it just says what is good for the goose is good for the gander. let's put the members of congress in it. we like what we have. we are telling the american people we're trying to give them what we have, so let's demonstrate leadership by requiring every leader of congress have to get their health insurance from the government plan. >> i accept the amendment.

>> well done, thank you. [laughter] >> let me object. >> in the so-called government- run plan says in the second sentence that no person is required to participate in the plan. no american, no penalty assessed against someone who does not participate. i do not know why we should not have what is cruz is good for the gander? we qualify, we did not give up our citizenship to become members of congress. i do not see why we should be required to participate in a plan that we are specifically saying no one else need to participate in because we are in leadership positions. >> if it is not good for us, it is not good enough for the rest

of america. >> we are protecting their right not to participate and we should protect -- protect the right of every american ought to participate, including ourselves. >> i would disagree. we're moving in a direction -- we are already under 60% under control of the government in this country. we are going to move to 70% and we are going to be a part of that. all we are saying is we should take the lead and say, we will sacrifice, we will give up our right to choose, and as a demonstration of our faith on how good this is going to be, we are going to put ourselves into the plan. why should we be giving up the right to choose that which we are expense of providing for every american? to demonstrate how wonderful this will work. >> i accept the endorsement of the senator from oklahoma. >> i think he may not have

caught my tinge of cerf -- sarcasm. >> if the idea is the government plan ought to be available for members of congress and staff and other federal workers to participate in, if they choose to, then i would agree with that. i would support that amendment. i think the right to choose whether you buy a private plan or you buy this community health insurance option or by your coverage through that, this bill goes to great lengths to ensure that choice is there for everyone. it ought to be there for ourselves, our staff, every american. >> every american is some said was an insurance to the tune of $12 million a year. what we ought to demonstrate to them is we have enough confidence in the system that we are willing to expose ourselves

to this system by taking the lead and giving up our right to choose. we are not asking anyone to give up their right to choose. it is just the opposite. we are giving people an additional choice that they can make or can reject. >> ultimately, you will have everyone in this plan. ultimately, everyone will be in this plan. >> you are the only one that believes that. >> cbo does not believe that. >> well, cbo has been wrong on every mandatory program quoted about the cost and outcomes. we can rely on cbo just like we can to the difference of what we said yesterday. other forms of competition on generally declined. you will lose jobs. that is what cbo said.

peoples whose wages could not fall. one program that creates work disincentives for the recipient is medicaid. that program is structured so that eligibility is eliminated as specified income for most categories. >> what does this have to do with your amendment? >> it has to do with the fact i know where we are going. you assume we are not going there but we have never seen a government program not role in health care. if, in fact, the government plan is competitive for people outside the plan, they are going to move to it. except it will never be financially viable because the secretary will set the rates. the only way you will have a plan that is going to be viable and have enough people in it is to have a lower rate than the cost, like the main public plan. maine has a public plan right now with 10,000 people in it and

they have increased the number of people uninsured. it is a failure. >> this may turn out to be a failure, too. i understand some of you do not like the idea of a public plan, but the idea that we can provide that as an option for all americans except members of congress and their staff who would be required to be in it, i think is it logical. i would oppose it. >> all those in favor of the coburn amendment, say ya. . say aye. [roll call] >> senator reid?

>> no, by proxy. >> senator sanders? >> senator brown? >> no by proxy. >> senator casey? senator kay been? senator white house? >> no by proxy. >> senator gregg? >> aye by proxy. [roll call]

[laughter] >> we are a team. a new coalition. i would love to be a little church mouse in the comforts committee when this is dropped. >> shailagh murray, you heard the senator joking about require members of congress to be on the public plan. it failed in the house, one of the few non-party boat in the committee. does this have any chance when it goes to markup? >> it is certainly one of those provisions that makes us very uncomfortable. i think that is the way it was intended. also, like many of tom coburn's amendments, he is making a

powerful point which is, do not pass anything you would not want to participate in yourself. so many of the problems in health care is because they are done in the third person without really thinking about the practical implications. >> we will presumably see this markup session in the coming weeks as congress returns to session. can you give is a snapshot of what you think will take place and how quickly they can get it done? >> the first order of business is for the finance committee to produce a bill. they are facing a september 15 deadline for these negotiations. very unclear whether that will produce a bipartisan bill or not. it will certainly produce a bill, and the finance committee, dominated by democrats, will be able to pass it. it willcoperoi think members coe

going to feel probably more conservative in their ambitions based on the town halls, based on new deficit forecasts, based on the overall cost pressure that they just do not want to take a huge risk. they want to pass something they can pay for through medicare savings and through these tax incentives. after the finance committee acts, the house will try to take its bill out of the committee and onto the floor and will probably make some extensive revisions, including getting rid of this wealth surtax that has gone over like a ton of bricks and especially with a lot of your younger democratic members. >> so this will be a markup session? >> essentially it will be a be

read before it goes to the floor. -- rewrite before it goes to the floor. they do not want to make any bold moves yet because some of the tax options could be adopted by the house. the big question going forward, ultimately, is how partisan is this debate going to become and the more partisan and becomes, the more challenging it will be, especially in the senate. >> what can you tell us about the cost of the bill on the house and senate side? >> the house bill we have been discussing was scored by the cbo at $16 billion over 10 years. of course, that does not include medicaid expansion, medicare changes and other issues that the finance committee has jurisdiction over. so it is not a phonebe