he offered some recommendations and concerns regarding the numbers. >> did you get those recommendations? >> i certainly will. that would be great. >> when we had a conference call, we wondered about the list of assumptions and what they

were based on. i do not think the outside numbers match the cbo numbers. do they? the totals are all we get from cbo. >> the current total from state spending this about $33 billion, and their words. our bottom line is lower than that, because we included our total calculation of the increase revenues you will get from restructuring the medicaid. if he took out the rebates, which are over 10, our bottom line #is 22. -- number is 22 --if the rounded, it comes to 33. it so, it doesn't match. >> can you show me which table at the to the $33 billion in state spending?

-- adds up to the $33 billion in state spending? >> our bottom line is $22 billion, because there is one additional item added impetus i do not think we share a table that said to 33. >> that is where my confusion comes from. in 2003, the question the methodology that your institute uses. the leads me to want to come up was some way that states can say your numbers wound up way off and we are in a declining economy. i like to exempt out until it can come up with the right numbers. that is the purpose of this amendment. about electoral call, please.

-- i would like roll call, please. [roll call vote] [roll call vote]

>> the final tally is 10 ayes and 13 nayes. >> the amendment does not pass. >> of like to offer my amendment numbers c-2 has modified. this amendment is a good amendment to follow up on the one that senator enzi just proposed. i understand the point that was raised by the senator that you have an objection to reducing medicaid at a time when there

may be difficulties in this is. i will talk about a minute the discussion we does have about the different numbers we have on it. i do not think we can ignore the fact that there will be some burden placed on the state by this legislation at a time when they cannot face it. any unfunded expansions would be particularly troubling given the state faced a budget shortfalls of over $200 billion over the next three years.

this gap persists after the increase and medicaid. what my amendment does is simply provides that we will not pose an unfunded mandate on the state. i recognize that the mark has increased the federal share significantly and the chairman has argued that the gap is very small. the cbo has an indication that and maybe different. i personally agree with senator and. it is a little bit difficult to accept that the -- since the number was not acceptable, we have additional studies that seem to reduce that number. the bottom line is whatever the

number we should not be imposing an unfunded mandate on the state. my legislation would compensate for the federal government picking up the remainder of that share by responding to a reduction in the chairman's mark. it would only impact of those making over $80,000 for their subsidies to be reduced a small amount for us to accommodate this burden on the state. this is an unfunded federal mandate issues. it is another way to approach the problem that senator and has raged -- senator enzi has raised. it is the opportunity to not put another unfunded mandate on the state at a time when they cannot handle that and when they will simply have to increase taxes on their citizens at that time. i would like to conclude by

indicating that i personally think that the difference is probably closer to what the cbo said. i have confidence in the cbo analysis in recognizing that they did not do the state-by- state analysis that some are trying to be engaged in it now. there are studies under way. we will hopefully hear from the governors as to their analysis of these numbers. if the cbo is right, we are looking at a $33 billion gift to the state. if the cbo is wrong and the numbers that the chairman has mentioned are more accurate, then this amendment would have a very small impact. my point is what we ought to do is take a position as the committee right now that we will protect the state's from yet another unfunded mandate and one

that could grow and about to be a very significant mandate at a time when the state can least afford it. >> mr. chairman, might i quizzed a step on a couple of issues that have been raised by this? -- might i quizzed the staff on a couple of issues that have been raised by this? is it not true that the expansion of medicaid does not begin until 2013? >> 2014. >> 2014 now. there is no expansion. nothing is asked edition of the state until 2013. is it not the case that in the first three years the state will actually get additional payment? >> that is correct. they will get additional revenue from the increases. >> the drug rebate from medicaid.

not only do they not face any change in medicaid until 2014, in the first three years in a get increases. numbers 3, is is not the case that the analysis that is being done not by the staff of but by outside analysts is that the impact over the 10-years to the state is on average 1.3%? >> that is correct. is it not the case that the estimate by cbo that have been referenced almost directly tracks the underlying estimates that have been provided here, the $22 billion plus the $10 billion of the drug rebate money? >> if i could just answer that and more than a yes or no to

clarify. cbo has been providing what they refer to as a three different table, coverage which comes in two pages. it shows increased enrollments. that is within 94% coverage coming. and spending and medicaid. they separately do what they do a medicaid provider table. the third table is their medicare table. cbo's footnote of $33 billion is on the covered table. it is what they predict total spend for states on medicaid. that is there $33 billion. on the medicaid provider table is for the drug rebates show up. it is not really have anything to do with coverage. our analysis combined everything

to present what we thought was an actual bottom line. had we done to separate tables the way that cbo did, we would have probably broken it up the same way. we have enough difficulty producing one table. i would have been overwhelmed by a second. this is so you could see what the impact of the chairmen of mark would be. >> that in fact that you have is almost exactly what the net impact of cbo has. this talk about a difference is a difference without a distinction. is the difference between showing it in one table and showing it into tables. i hope we do not get distracted by the difference without meaning. beyond that, there is no expansion until 2014. in the first three years, would

that be 2014, 2015, and 2016. >> the first three years of the budget window. >> they will be getting extra money now. >> right away. >> honestly, if there is to be shared responsibility in this country and it is all to be on the federal government, the state have no responsibility for anything when this expansion does not even begin until 2014 and then the estimates are it has a combined impact of 1.3% on average. we are good to have a real hard time dealing with problems across the country if it is all supposed to be in the federal government. it has record deficits and record debts.

they expect the federal government to write a check for 100% of everything. i do not think that is a reasonable expectation. to be asking them to put out 1.3% on average over the next 10 years and the expansion does not even begin until 2014, i do not know of any prognosticator who thinks that the economy in the united states is going to be in recession until 2014. i would hope that we would resist this amendment and go forward with the mark. we had the conversation with the governors, and they thanked us for how dramatically we had improved the package from their perspective. >> that is true.

they talked a good about it. >> they thought it would be bigger. >> they thought they were going to get a hit. they felt pretty good about it. >> the question of -- has the hospital addition been included in the numbers? it is my understanding that there is a $2,500 impact. has that been included? >> that is not in the table. everything in the table is identified. but wouldn't it be true that during the same time frame that we of in discussing the states will lose $25 billion under the hospital provisions? >> see below's total is $24.9 billion. >> i think you see my point. we are starting to look at income to the state to balance

it off against the impact of the medicaid expansion and argued that we have new charts that we can show the impact will not be as large or it is different than what cbo estimates. understanding that the impact is not start until 2014 does not mean there will not be an impact. secondly, if given that the drug rebate, you should also look at the hospital dish impact and the balancing it on the state into the analysis before make it final conclusion as to what the impact is. we have a disagreement over what the chart are saying and whether it is a 1.3% in fact or a $33 billion impact. my point is that medicaid spending is the fastest growing line item in every state in the country. in 2006, it accounted for 23% in

every state budget. to say that we need to have a shared opportunity here to pay for health care between the states and the federal government ignores -- and to imply there is not already a major share of skinning in the game on the state -- i think is a mess characterization -- aim mischaracterization on stage right now. urging states -- on states right now. all my amendment does is say that there should not yet be another unfunded mandate on the states. i think it is a higher unfunded mandate then apparently you do. whether it is 1.3% or not, one

way or the other, we have got to protect the state from the impact of one more federal mandate at a time when the states are in dire circumstances. >> i wanted to briefly support what you said. if there was a litmus test on whether this is a burden on the state, it to be from the governor of michigan. the work that has been done is reasonable and what has happened is something that is minimal on the state -- i think that reflects pretty heavily on the burden over all that is being provided or put on to the state. the trade-off is being to not

only help the states, but more importantly families that have been in very difficult times, who find themselves out of a job, who are now low income families, seniors -- all of those were impacted by medicaid. there is a huge that you on what is being done in this mark with minimal concern about a state that is under concern. >> on the point that the senator made, he analyzes things very thoughtfully. the reason we are able to make reductions in the dish payments is because there is going to be less uncompensated care, and

dish payments are to offset all comments a day care. -- uncompensated care. if we make a calculation that includes all of the elements, the states are going to have significant benefit that do not show up in any of these calculations. if we were going to do a full copulation, we would need not only what is going to happen to dish payments, of what is also one to happen to the reduction in uncompensated care. >> uncompensated care affects the average family of the $1,100 a year in more coverage.

it would go down very significantly. we are all concerned about the rise in medicaid costs. the governor is more concerned than we. the major aim and goal of this legislation is to start to reduce the rate of growth in health-care costs in this country. it is all government of budgets. -- governed budgets. we are trying to reduce the rate of health care costs in this country. >> let me just respond briefly.

i understand the point that senator conrad has made about the dish payments and about whether we will be reducing uncompensated care. i am aware of the we also have about 25 million uninsured after this legislation is passed, it is passed. we do not know exactly what it will be. my point is that if you are correct and the issues that we are raising are not as serious as i think they are, then the impact of this amendment is not that serious either. all it does is say if there is an unfunded federal mandate to the state's rising out of this expansion of medicaid that we will not put that burden on the states.

if the burden is as small as to indicate, there is a small fiscal impact that is accommodated by the offset. the only other point i want to make is i understand that a number of the governors have expressed relief. i think the point is not that they were expressing relief that they were going to be able to share in in this additional fiscal responsibility. i believe it was an expression of relief that it was not as bad as it appeared that it was going to be. the bottom line here is, very simply, we do not at this point in time -- we should not be imposing another unfunded mandate on the states. i'm concerned that it might not be. whatever it is, we ought to be sure we do not impose it. >> it all comes down to a very simple point. should there be shared responsibility?

i think states should share. 1.3% is not asking too great a share. i think it is right. >> states already share extensively in medicaid. >> i just want to as several more questions. -- to ask several more questions. effective january 2013, states would be required to provide premium assistance to medicaid beneficiaries that had insurance plans. how much would that be? what is the fiscal cost to the state? >> the way that premium works is state only have to do it if it

is cost-effective, which means that it cannot exceed the cost of what they would not provide services directly. >> is that 100 term? 133%? >> it would include the expanded population effective january 1 of 2014. what did the mark does is -- >> but not in 2013. >> correct. that was to sink it with the advent of the exchange. what this does is -- currently states have the option to offer premium assistance or not. this takes that option away and says all states have to offer

that option. it is a better way -- it is the way to better employs sponsored coverage. this is a way to help of the report is. >> that is there additional requirement on the states. it changes from optional to required. >> that is correct. >> what will be expected to cost the state? >> i do not know that cbo broke that out individually. i do not think that they treated for to get into a premium assistance versus who comes and as a traditional medicaid enrollees. the cost of providing premium assistant to beneficiaries cannot exceed the cost of if

they were in the fee-for-service medicaid program. >> we have expanded our populations. i know the governor of vermont has expressed this concern. they have made separate requirement until 2015. is it fair to require the states maintain high eligibility standards of until 2014? there is no possibility in this economic time. the budget deficit is projected -- a consecutive budget deficit

year. they are required to balance their budget. it offers them little flexibility. i am not sure i understand the assistance to those states that have made investments in health- care and expanding the eligibility standards. now they are required to maintain that level through 2014. those who have been leaders are being penalized. the only choice they have is to cut the payments to providers and to cut the benefits. i think that is counter to the goal of this legislation. i am not sure that is fair and equitable for the state. that is an area of serious concern. some states are at 28% of poverty level.

some are at 206% of poverty level. those with two and a 6% have to stay there until 2014. -- 206% have to stay there until 2014 fr. we want -- we all want to include more people under the insurance umbrella. i think we all have to think about the context of what the states are facing. these are going to be some very serious budget constraints. they will face them over the next few years. it could well go into 2011, 2012, 2014. there have been some recent reports that demonstrates that budget levels will be at the same level they were in 2007 even if we emerge from this recession.

>may i add another point? in the stimulus plan, we did have requirements but we also provided some funding. in this instance, where does seem the had to maintain the highest level with no additional funding. >> i guess of a judge responded a couple of comments. i think everything you said is right. those are some of the concerns we have had in an effort to strike a balance, we did we have had. and ever to strike a balance, it did in an effort to strike a balance, -- in an effort to

strike a balance, lets users date for example. if the maintenance of efforts that all states are under in the recovery act, it the following day main it decided to sell back its coverage, the people are no longer eligible for medicaid will become uninsured. the chairman's amrmark makes thm eligible for the tax credits in 2014 when the expansion of medicaid kicks in. i think that stands in contrast to the provision that is in the house bill, which is a permanent effort which we have all heard

that the governors recently dislike because it forever limit of their flexibility. -- limits their flexibility. >> i understand that. it is less burdensome than the requirements in the house bri. you are putting enormous pressure on the states to make early investments. that is why we have a kind number of injured in our state in maine and vermont. we have made those investments over a sustained amount of time. we have to be cognizant of that. we want to meet the bottom-line goal of increasing the number of insurers. he had to be sensitive to the fiscal constraints on states.

>> i have an observation. it is interesting listening to a number of the arguments. this one is subject to a federal standard mandate. i understand the tension. there is a tension about the impact of a reduction here or there. there are only two ways to end because her. you either cut what we are putting out are you find more revenue to put in. we all understand where the politics are in finding additional revenue. under this bill we get an extra

four or five years. is that what we get? three years. that is all we are getting. we are sitting here with a much bigger problem sitting over our heads. there is a political will here to address. i think we have to remember that. they are really only are two ways to do this. you have to find a way to fund this. in this case, a decision has been made to reduce what is. or people are going to be covered. my question to you is, is there any other calculation that has

gone into arriving at that figure of this reduction is there any other calculation that you are able to make that is of consequence of things they are doing in this bill or in the health-care system that will have a reduction of any kind of negative impact? >> i should add that currently there are six states that have what cms refers to as district of version where they have gone through the process and have been approved to use the dish dollars to underwrite coverage of people that traditionally use

it. three of those six states have diverted 100% of their funds toward coverage. the other three have partial diversion. massachusetts is a 100 and diversion. part of that is funded with edition dollars. the challenge marks any dish dollar that is diverted from coverage to the kite. and dish allotment would not be reduced. i think you are diversionists 52%. do not quote me on that. it to be subject to the cuts. over time, it cannot happen before 2015. it is incremental over a period of years.

>> one must question if i could. as i study this chart, it tells me that over the next three years, every single state will have less in medicaid spending because of bismarck. is that true? >> that is true. >> i'm going to have an amendment in a little bit. one thing that i wanted to point out, sometimes we talk in weird numbers are around here. anybody that has been around here, some of the numbers we toss around and the ways we speak, and the american people scratch their heads and ago,

that does not make sense. when we say the medicare trust fund is extended out three or five years by this legislation and we say it is solvent for that year, it is like saying i have this idea that i owe my kids' college fund x amount of dollars. i make a number that i extended out. because of my rate of borrowing and spending right now, i am not one of the money to pay the college fund. it is not really matter. if the money is not there, and we know the money is not there in the medicare trust fund, the bottom line is our amount of money we spend on the debt is around $180 billion.

by the time that this budget window is fixed, our interest on the national debt will be somewhere around $800 billion a year. those are accurate numbers. when you are paying $800 billion a year, that is the biggest threat to medicare. we are not want to have the kind of money to be able to supplement -- and going to have the kind of money to be able to supplement. that is why i am saying that spending is a big deal here. this deal spend money. you brought this subject of about the medicare trust fund. when you make a point, it is fair for us to respond. >> i think it is fair to respond. a fair response requires an acknowledgement that almost everything we have done here we

have tried to make these bills a deficit neutral. everybody has led the committee to that. we all know what happened in the base -- last eight years. >> i'll compare my record against anybody on this committee. let me reclaim my time burd. >> we have to vote producing here. >> we are seeing appropriation's bill after appropriations bill to recommit the bill. not a single democratic vote. i did one last week because last week's spending bill was 23% higher than the year before. this week spending bill was 15% higher. we are spending money like crazy.

we establish clearly the one in the reason they say it is unbalanced is because the catalog is a cadillac plan -- because the cadillac plan is picked up. we also understand that some of the revenue raisers go into effect within the first few years. the estimates could be as high as $1.70 trending. >> ready to vote. >> roll-call vote. >> know. >> no. >> past. >> no. >> no by proxy. .

>> no. >> no. >> pass. >> no by proxy. >> no by proxy. >> pass. >> aye. >> aye. >> aye. >> aye. >> aye. >> aye by proxy. >> aye. >> aye. >> aye. >> be chairmen votes no. >> no by proxy.

>> mr. cantwell? no. >> no. >> no. >> the final tally is10 ayes and 13 nayes. >> i'm going to offer this amendment. >> what is the number? >> number c-8.

it is on behalf of myself and senator bingaman. we do not have a cbo score yet. we wanted to speak about it for a brief moment. we will move this amendment as the go forward in the process. what it does is make american citizens living importer rico, gong, samoa, eligible to purchase health insurance in the exchange and receive federal subsidies by the residents of the 50 states. i was dismayed to find that the mark to not allow these u.s. citizens who happen not to live in one of the 50 states access to the reforms that are such as signet again part of the bill. there are 4.4 million residents

outside of u.s. territories. they are american citizens. porter ricans have been part of this nation for 1100 years. it as these residents to also benefit from the consumer protections established by this bill. they would be said to the same mandate as everyone else. -- subject to the same mandates as everyone else. we want all americans to have equal access to quality and affordable health care. everyone recognizes the contributions the territories may to our country. puerto rico send more men and women to our armed forces than all but one of our states. the residents of the territory, also pay all federal taxes but congress has asked them to pay

including medicare and social security. they should be able to benefit from health care reform. there are 4 million men and women living in the 50 states who were born in puerto rico, 1 million in my home state of new york alone. how can we tell the citizens their loved one in the territories were not able to access to the benefits that come with the insurance market reforms and participating in the exchange? we are offering this amendment so we do not have to tell them that so we can say to our neighbors and fellow citizens they deserve the same health care reform and that we do. we have not received a score

from cbo for this amendment, but i hope we can work with the to find a way to include the territories in the exchange. it is the right thing to do. i believe senator mendez would like to speak on this. >> let me thank my colleague from york for offering a amendment that i co-sponsored with him. let me start off with that. sometimes i had members of congress ask me if they need a passport to go to puerto rico. i thought it was a joke when they ask me that. they were serious. they are united states citizens. if they are united states citizens. the flow that goes back and forth between states that -- its

quite big. if they happen to them come to new jersey for an amount of time and maybe stayed, they would be eligible for what we are reviewing under this bill. if they move back to puerto rico, they are not. there are nearly 4 million united states citizens who reside in puerto rico. they pay the same medicare taxes as any other american in any state. in my book that is coming out, i talk about the 65th regiment infantry division of the korean war. all the puerto rican division was the most highly decorated in the history of united states. the good to the vietnam wall,

most are of puerto rican descent. i feel they as well as all the territories must be part of the health care reform. they must have access to the subsidies of healthcare. that is why i am proud to co- sponsor this was senator schumer. ironically, the bill would treat legal non-citizens in the state, legal permanent residents, better than american citizens living in the territories. that is simply not right. in the interest of time, let me broach an amendment that i will not offer so will not have to go through this. let me take this moment to say that there is another amendment i was going to offer on

disparity in the medicare system in puerto rico. they pay medicare taxes but of my amendment would have provided for puerto rican hospitals to be paid based on the national average standardized rate. the form the yield payments to hospitals and are considerably lower than payments made to hospitals in the states. that is something -- the lone exception -- loan inception is deemed to have been enrolled -- the lone exception is puerto rico. i have a real concern about fellow citizens to have been to live in puerto rico. the centers for medicare services report that us of

december, 12.5% of par b enrollees inpuerto rico were subject to the late enrollment penalty. i know you have been a long term supporter of the territories in terms of fairness. i hope we can work on this issue as it proceeds. i know this is more cost them policy. i look forward to working with you as the move forward. it is not fair -- if you can mend a pose in afghanistan, if you can be injured by an explosive device on behalf of the country, you should be able to have access to the exchange in the subsidies therein. that is what we seek to be able to accomplish. ipc for bringing the amendment forward. >> -- i appreciate you for

bringing the amendment forward. >> i want to show my strong support for this amendment. he indicated that he is received questions from congress as to whether you need a passport to go to puerto rico. i get the same questions about people wanting to go to new mexico. what you do not need a passport there. you need a visa. >> it says more about the members of congress than the areas we are talking about. i think we tried very hard to do the right thing by puerto rico in the bill the we did for the health committee. i think it is important that we do the same thing here. i know that this is not going to be voted on now. i do hope was the bill moves forward, we can figure out a way to bring fairness to the treatment of citizens in these

areas. >> i think you bring some very good points. a u.s. citizen is a u.s. citizen regardless of where they live. it would seem to me to be a matter of fairness. i hope we can work this out. >> i withdraw the amendment. but with a drum. -- >> withdrawn. >> i call up my amendment c-23 has modified. i remember when the cbo director talked about the fastest safe speed at which this bill and various amendments might be scored. i know senator schumer said his amendment was not scored nor have many amendments been scored. i understand what. i am not critical of that. i am just saying that is a fact that we have to deal with.

as many of us have observed, this proposal overhaul's 1/6 of the economy. 2.6 trillion dollars. i'm concerned the process is being a german by an artificial deadline. this is september 24, 2009. the main spending in this proposal does not go into affect until 2013. as we have discussed, the medicaid expansions do not go into effect until 2014, five years from now. i believe is imperative that we get this right. i have heard members on both sides of the aisle say that. over the break, i learned the cbo made a mistake in scoring the amendment that was accepted by vote today. that was c-6. it was a $600 million mistake.

because cbo had said it was revenue neutral, no osset was required by the chair. i do not blame the chair. i do not blame the cbo. i do not blame the senator. i believe the unrealistic time lines which are artificial that have been imposed contributed to the $600 million mistake. $600 million may not sound like a lot where talking about trillions of dollars, but six and a million dollars is real money. his amendment has a worthwhile goal. we also deserve to have an informed debate and to get the details right as we are voting on them. to ensure that kind of mistake

is not happen again, i would propose my amendment c-23. my amendment is designed to simply slow us down so we can get it right. it is not to slow it down for slowing it down and say. my amendment would require that before the finance committee votes on any amendment to the americans help the future act, the scoring estimates must be publicly available. it must be posted on their respective web sites for at least 24 hours before a vote. this does not need an offset. it is designed to help us save money, not spend money. i would urge my colleagues to support it. >> you seem to be the subject of it. >> i do not know how many times

-- i did want to clarify one thing. the amendment that i offered today i recently raised with the chairman, that there were some debate going on with cbo and whether not it was s cored. there was an intended to change it. the rules making process was started and never finished. the cbo's score that? this really had nothing to do with rushing in the bill. it is an ongoing discussion that we have now with them. there was a communication that in fact it had scored it 0. it was a mistake and communication. we are still having that discussion.

i would not characterize it as being part of somehow rushing this process. it is more of a question of how they score and what is happening during the rulemaking process. we are still debating with them. we believe that there is no score. we are still discussing it. we will continue to do that. this is not a good example of what you are talking about. it was something that we have been having discussions on for some time. >> just so she understands come i'm not been critical of here. >> i appreciate that. >> the fact of the matter is that at least one of my amendment was rate -- ruled not germane because there was no score. he ruled it out of order. the appeal from the chair was

unsuccessful. conversely, a dissenter from michigan's amendment was a voice vote did because cbo said it was revenue neutral when in fact they came back and said it was a $600 million mistake. and not being critical of the chairman are the center for michigan. i am saying this demonstrates how trying