>> i think that's right. >> so thinks more. i guess that is what senator this is about 23 or $24,000 a rockefeller says we are doing person. here. >> no. >> senator, that's a multiyear >> no. figure i believe you're quoting. so you would have to divide it >> it is the president alone who by the number of years. if it were 10 years it would has the authority to present the divide out to -- names to congress. >> how many years did they estimate per person would be on there? >> if we decide not to approve >> the total budgetary cost? secretary of state -- if the >> ok. >> so it ends up being about $2,300 per year per person. >> i think that's right. congress says we do not >> ok. >> that's not right, either. >> no. approve them, and that person >> and the bring doesn't start does not get approved. in this case, the president can until 2014. ignore our recommendation. -- the bridge doesn't start until 2014. >> let me make my point without >> you have the order reversed. specific numbers. we confirm after he appoints. it's very expensive. >> i appreciate that. >> it's very expensive. >> you are saying that the law if we were, for instance, to do or decision required us to structure it this way. i'm saying that is not correct. in the abstract put all medicaid people onto an exchange, it

would be hugely expensive, >> are there any lawyers on the probably not for better care. step to compare five this is the they'd be better off going to only way we can do it? community health centers, rural health centers, places that are >> yes. within medicaid but by all acclimation give excellent care. >> would any like to volunteer? and it gets to a bottom line >> we will verify that. here. that we can do all the exchanging around both from the public system and private system are expensive and getting more >> can you explain the expensive. we'd better get at the cost. and getting the cost down. requirements? because if we don't, all the >> anwhat i have never been on exchanging in the world won't make a difference. we're not going to be able to afford healthcare, either for the poor or lower middle class with subsidies or for average middle class people just on this side. their own. the supreme court held that the and so to me, this argument which is better, public, private, private, public, i comptroller general cannot make don't have a dog in that fight. i think both have shown to give across-the-board cuts. good care for a lot of money. congress had the ability to and the reason is our delivery

systems, the reason is the kinds of inefficiencies, the reason is remove the comptroller from the lack of prevention. analysis -- from office. and this amendment i believe they will have the authority to will cost a lot of money, maybe make cuts unless congress passes a law to stop it from going into 50 billion the chairman affect. estimated. for this commission to be .. constitutional, the president has to have the authority to appoint. it also involve the nominations to the commission as well as in the confirmation process. >> the comptroller cannot do it because congress could remove him? even though the individuals will be appointed by the president, how is this put into office? >> by the president. removable by congress.

isn't that the purpose of what we are trying to do it? what's the difference is that if it is, we are going to be his removal by congress. able to get back into the these individuals would not be. details exactly how the subsidies would work. you nineand i -- you and i >> [inaudible] have talked about it being 4%. >> what i do not understand is it is important to establish the why that it affects whether or principle. if i understand it, you want to not the president has to appoint address the portability without all members of the commission tying people to the program that and none can be appointed by the congress. >> [inaudible] very much need to reform. is that your intent? >> absolutely. >> the congress is not making >> can i ask a quick question? appointments in that case. >> i will be very brief. >> congress was too involved. there is a hybrid of this in arizona. from the beginning, and they have had a waiver from medical -- from medicaid. it is essentially hmos. that is why the ruled it i do not know what the cost is.

it would be in between. unconstitutional. we responded by granting power there is a lot more integrated in chordata care, which is what to omd and making cuts. hmo's do. i'm not sure that it would -- that think the quality of care would actually be better not wars. -- not worse. >> we are going to vote. i think having options it does make sense. >> i object to calling a vote on i hope that colleagues would this. support this. but i ask for a roll-call vote. >> thank you. >> can ask a question? [laughter] aye. can you currently give waivers aye by proxy. to provide premium assistance aye. to medicaid patients to go into aye. the marketplace? but that is absolutely right. senator kyl dismayed that point pass. aye. for the goods some of that can aye. be done now. aye. -- senator kyl just made that

point. aye. >> some of that can be done now. aye. >> they certainly have that aye by proxy. option. aye by proxy. >> just briefly, i agree with pass. the chairman of that it is a no. problem with three spect -- with respect to affordability. we made a pact to improve affordability. aye by proxy. this would undermine some of those changes. i think that to be unfortunate. i believe the senator indy has pass. no. opened a discussion that really does merit more attention. pass. in the medicaid population and certainly when you expand it, pass. there are those who benefit aye. greatly from the more extensive pass. array of services that are provided there. no. i talked about some of that in aye. the gang of 6.

a gentle man has to be helped out of the bed in the morning. aye. he is paraplegic. he has to be helped into bed and night. he did not have that kind of service that is not available in a difficult insurance plan, he x. you can tally the votes. and not a productive citizen. this is somebody that goes to work and works eight hours a day. he is a taxpaying system. the only way he is able to function is people helping him get out of bed in the morning and getting to bed at night. there are others who have a different circumstance who are going to be in the medicaid expansion population here might be better off with an alternative choice. the final tally is -- a more basic plan, one that will be more expensive. >> it passes. before we throw the baby out with the bathwater, i cannot vote for your amendment as is >> the rockefeller amendment because the paperwork. passed, 15-3, with five members i think you have open of the discussion that merits more attention. >> i have a question for

senator enzi and what income of the population are you talking about? >> we are talking about the zero to hundred thousand population. the others have a choice for the >> how would they get private coverage? >> beheading it was with the subsidy. -- by having a choice with the subsidy. >> i think this is a very important discussion fo. have been quiet here for the last 24 hours, but working hard on something that i think is very important. it is interesting that the other side has offer so many amendments to cut the subsidy and do various things for the lower income population with the

reductions. you are serious about that, i think it is very good news for america. this is about driving down the cost of healthcare. many arab-americans as may be to subsidize insurance, how are you going to drive death -- many americans are asking about how to subsidize insurance and hire good to drive down the debt. i truly believe that you can provide coverage for the same population that you are in providing the tax incentives for for 25% less. and did giving subsidies that will prop up the price of insurance, we create a market that would drive down the cost and provide less of a burden to

the taxpayer. there is an additional benefit. by creating the market, we also show efficiency. the more efficiency we can show in the market, the more we all win. the competition is there for the market place. i have a concern about how you are paying for this. the wonder if the senator would consider, since i have amendment that is addressing the population between 200% -- up to and a% of poverty in saying we could provide cheaper care. the reason i'm asking this is because he is bringing of choice. this is about whether with and provide enough competition in driving down the price.

i think there is a way year in which states can play a role in helping to negotiate for private coverage and get as better coverage. in some of us giving a tax subsidy of 200% of poverty so that they can go by $6,500 insurance and their contribution is around $1,900. of we in washington have shown they even have a basic health plan and the costs are probably half of that and the individual contributions are half of that cost. i think this is very much worth exploring. i think the way it is that it is problematic. i would as senator in the few consider engaging -- if he would consider engaging -- there are some of us who believe this may

be an important compromise that we could work there. >> i appreciate the offer to cold and a look at something new -- to withhold and look at something new. i will ask for a vote of this time. this is the thing that i have been bringing up for months. we are not being fair to medicate people. we need to be fair to medicate people. -- medicaid and people. for now the way we are handling costs is to cut back on the -- on what doctors get. as a result, that they will not take medicaid patients. it is not good for medicaid patients. the cannot see a doctor and you do not have insurance, there is a stigma to have a medicaid. part of that is because doctors will not take you.

>> i'll let you finish my statement for the yo. you can save money to cut back on the doctors. medications will not be able to see the doctors. and not had the score. i know how tough it will be for me to get a score. one of the things i want to emphasize right here is that this shows how big the problem is that we are trying to work on. we have never had a bill in the history of the night it state that has incompetence at the the everybody in the country. -- encompassed everybody in the

country, every single business, every single provider. we are doing that. we are doing that in one heck of a hurry. we have not had time to talk about this medicate option for people can have a choice if they are under medicaid. i'm willing to bet it is going to be a bigger topic them we can cover in one hour or two hours. anyone of these things could be a stopper. there are some questions the need to be answered. if we do not enter them correctly, america wind up in a real hole. we do not want that to happen. i wanted to emphasize this problem have of forcing people into medicaid. -- and not giving them the same kind of the till we are talking about.

>> mr. a no. no. no. aye. no. aye. no. no by proxy. no. no by proxy. aye. aye by proxy. no. aye. aye. aye. aye by proxy. aye. aye. aye.

no. >> the final tally is 10 ayes and 13 nayes. >> the amendment has failed. >> i like to call up c-4 modified. >> it is not an explosive amendment. if this symbol rohm & hoss ahoy. -- it is simple. >> this amendment is rather simple.

this amendment is rather simple. it is also budget neutral according to the cbo. it provides for a child only help insurance option in the exchange. it allows children to qualify for coverage in the health insurance exchange and ensures access to any subsidies for which they may be eligible. one might ask why this is important. i would urge my colleagues to think of a family whose parents are exempt it from coverage because it is unaffordable. unless there were insurance -- insurance programs in the change shows for children, they would have to sign them up for adult coverage which would be much more expensive.

[unintelligible] the amendment is essential to ensure that all children eligible for coverage continue to have access to affordable health coverage. this is particularly important because under the chairman's mark, an order for them to receive benefits if they must first obtain private coverage. if one would think about a child aging out of foster care or consider children and parents whose employers do not offer dependent coverage or a child living with a grandparent, in this instance the grant their profits of their health insurance, medicare. homay be the grandparent is not have income by the social security.

how would they get a tax credit? we need a place for them to be able to go. that is what this amendment does. tax credit and subsea determinations are made using taxpayer information even if a child could access a child only policy in the exchange. it is unclear how children will qualify since they did not file tax returns. the amendment would address this issue by addressing the secretary to determine whether alternative means are necessary to provide support it is essential -- to provide support. >> could you -- how would this

and let her body structure? rohm & hos[please stand by] >> it sounds as though they already assumed there would be policies. they have the plan today. they did not think there is any effect. >> all in favor say aye.

>> aye. >> all pose say it no. the aye's have it. >> i would like to call up my amendment c-24. we know there has been a lot of discussion about choice and competition during this health care debate. i certainly agree those ought to be to attributes -- two attributes of what we ultimately embrace. i would note that the only place we currently do not have competition in 58 americans under attack in a row on medicaid program. they are said to lot more

americans in this program. it did not support the medicaid expansions in this bill. medicaid is not working for the present population, much less the expanding population that would be called for. 40% of physicians restricted access for medicaid patients because of concerns about reimbursement and billing paper where -- paperwork. in california, only 51% of family physicians participate in medicaid well in michigan, the numbers of doctors who receive it has fallen from a high of 88 serve half a the sermon haag to 64%.

medicaid patients are almost 50% more likely to die. according to a recent survey, there is an acute -- an excuse -- an acute lack for medicaid patients.

why we do expanded program program rather than fix it? if it passes and they believe it is a worthy program that provides access to quality care, we should lead by example and be willing to enroll ourselves and our families. we do not deserve to get health care benefits and choices that are unavailable to the people that we serve. this amendment would require all members to enroll in the medicaid program in our home state. i can guarantee it this amendment passes and is incorporated into the final legislation, medicaid will get fixed.

>> i think we did some of our worst work at these late hours. this is a good point. [laughter] >> i second day motion to adjourn. we will call on the current amendment. no. no. pass. no. no. no. no by proxy. no.

no by proxy. aye. aye by god -- aye by proxy. [laughter] aye. no. no. aye. aye by proxy. aye by proxy. aye. hobbno by proxy. >> i have a boat change.

-- vote change. pass by proxy. the final tally is sixth ayes , 16 nayes and 1 pass. >> i like to take the temporary recess. the committee stands in recess for 15 minutes.

x a short 15 minute break to give the finance committee voting on amendments. they say now appears likely to spill over into next week. that is due in large part to the sheer number of amendments filed by the bill. it says the mood of the markup has been fraught with tension. senator baucus and senator kyl had a testy exchange today. well we wait for the committee to return, more debate from earlier today.

>> thank you. i suggest that it was kind of frivolous there were too many lobbyists involved. it was difficult.

a lobbyist comes in and represents an enormous invented by having an increase in the reimbursement rates for oxygen or for something else. i said i thought -- that the coniston -- congress has made an earnest effort to try and do arithmetic -- to do a medicare reimbursement correctly. they are doing it for more accountability and outcome based research and application. they are not lobbyists.

they are not sending congressmen or senators. my original approach was modified to working with the chairman of this committee. as i indicated, senator karpo made an impression on me. there is a lot of talk about government involvement. this will not be without government involvement. this is where i made a compromise. congress should be involved. i made that a modification which the chairman has graciously accepted. this would be the way it would be done. it could be 11. it could be 15. it is not decided.

this is but did neutral. there is no offset needed. they would present the ideas that are the names of the people, their credentials, something about them. i believe they would have to be approved by the net state senate. >> that is true. >> that means by us. that is legislative involvement. i like that. i feel better by doing it that way. i think it has a better chance of passing their by. -- thereby.

the purpose would obviously be to make wise decisions. this so-called medpac --and we do not even have to call it that -- was put before us by the republicans. it was accepted. it has been dutifully putting out every year but knowing they have no authority empowered to do anything about they have been putting out a suggestion about it. they have been putting out suggestions about how it should work. all of these things are involved. it is a very difficult decision. it is a constant city. nobody would be able to serve on this group was not fully

involved. there are three official positions, hhs, cms, and hera. they would be on that if approved by us. medicare is too important to that it be done from a slit. that it be done from this. say it is done by professionals. people that know the business. she is a very strong republican. she also knows healthcare and the back of her hand. it has been her life. i have no idea whether she would

be interested. a professional in public policy who knows the problems of the country, that said the with the needs of medicare might be for reimbursement purposes. it is very important. -- it is very important that hospitals and doctors are really feel that they are being treated fairly with an even hand. i think this amendment, thanks to the cooperation the committee, is a very fair way to do this. i think it is bipartisan. it has executive branch involvement. i do not think they will be entirely happy with this. but think they wanted it all to be a branch of the government.

i would just end by saying it is enormously important. i cannot think of anything that is more important. the chairman was also good enough to remove the three or four year sunset. . it will stop at that point. that means that people will of confidence in it. they had confidence in the ongoing process. then they make their decision. it then they come -- the decision comes before the congress.

the houses have a chance to review it. they had the chance to review it for 30 days, the product of the commissioners working long and hard for the full period of the year. it is a good amount of time. they could go over it and have a chance, if they were displeased, override suggestions. that provides some iselin -- some discipline on the legislature. i think this is a game changer.

i think it is a large idea. at the it has large consequences for the future. they will not just been looking a paying people but they will be looking at quality of the work, out -- accountability and outcomes. all of it is so important. i would put that before my colleagues with the hope that they would find it important. >> i very much thank you. you have been in the -- before friend champion of this concept. -- the forefront in of this concept. i think it is a great idea. cbo also gives it a very

positive school. it is one to save about $23 billion in this budget window. that is not a bad thing. we all talked about spending the cost curve. there is a lot of talk about it. there are not many provisions. there are several. this is one of them. it does bend the cost curve. the committee very valuable contribution to the country with this concept. we may not see the benefits of it for a few years. i do think we will see it in our lifetime.

thank you very much. >> thank you. >> me at this as the question? -- may i just ask a question? i do not see this in the amendment itself. may be i missed it. >> he put it in the mark. >> this amendment is basic imprudence up on the mark. >> this is regarding the congressional procedure. what has been removed from the mark? is it the entire process that is reported to the finance committee? if not, it to be reported to the floor of the center had a chance

to show is it? >> it is all part of it. >> it would enlarge the role of the congress. >> in what way? >> it could have an exercise of the executive branch of government. there are still part to me that think that makes sense. there are more parts made that thinks -- and believe this was a concern that you had -- the legislature would get -- would be let off or get out of the process. and my original proposal, they would not even get to vote on it. this gives the congress a much more power.

more have made their suggestions. but it to be the same time frame by which a report would have to be improved? >> yes. this will not take effect until the year 2014. that is important. it'll take that kind of time to prepare. they will have to have more staff. they will have to have more resources. they have been doing this for 12 years. now they will no that it'll be more likely to have an effect. >> this is basically what the group of six is asking.

you could get the beneficiary of quality care. there was a g a. o review -- came goa read you. >> no son said index -- no sunset? >> there is no sunset. >> appeal can do that work for so long and then they may do something else. you can put in place an institution that would be there in the future. >> in addition to the three members, is the membership of the commission changed in any way from the mark? >> it is not.

those three main people -- >> the other members are selected house? >> by the majority leader and the speaker. >> but not by them alone. >> but appointed by the president. but i have a question. >> i heard you describe this commission. you compared it to the braque process. it is bringing in experts. and. it was because we did not have the political will.

in the braque process, the the commission got set up ended its work and was over, why would we need in this case to continue its? once they make the recommendations -- >> the requirement to reimburse continues to do what i know. it has always been -- continues. >> i know. it has always been a comparison. the commission has one set of faces they are going to close. it does not affect most days. then we make a vote. that is that. >> the comparison was that it

was created because the congress did not have the political will. as these would be very difficult political votes, it if they came from up or down, it may be easier to get a bipartisan agreement to where we say it is for the good of the country. let us do it. the concept does not change. we had around one. we decided we needed to said the rounds. then we passed braque to. wouldn't it be reasonable to do this and say if it did work. if it were to the first time, we decided we needed to do it again.

>> we have that bureaucracy. it is just that it has no authority. >> we did none of the we needed the second ground that we did. here we can avoid having this commission make any recommendations to their congress if we do our work. >> i agree with that. >> i am touched. >> we have it in our power. >> we understand that. we understand who we are. >> i do not want to go down that road.

>> jesus says "and val sayest -- thou sayest." >> add a question of the language. -- i have a question on the language. there anything in the amendment that would affected? >> there is not. the commission would still have wide latitude. and they could recommend that it would have little incentive to suggest a repeal of the amendment. >> your first statement was that it has no impact? thank you. >> i have a question, too.

"the senate majority leader and minority leader will each% three recommendations for appointees to the president; however, these recommendations in no way would limit the president's ultimate responsibility to present congress with qualified nominees, quell does the staff read that nominees." this is every that to ignore the recommendations made by congress? >> the answer is yes. >> the president could ignore the recommendations of the members of congress and present a totally different name? >> let me jump in here. this is a constitutional requirement. the president has to make the appointment. we have the authority to confirm

or not confirm. the minority makes recommendations to the president for the unborn -- president. >> let me be real clear. i do not believe the decision prohibits the congress from legislating along the following lines. what is of the comprised of 15 members, three members appointed by the speaker of the house, three by the minority leader, three by the present, etc. we can create commissions with membership that we create or membership that the president creates. that is why i asked senator rockefeller the question. >> it is a constitutional requirement.

these are executive branch decisions. there has to be a presidential appointment. >> that is only true if one situation pertains. the power of the purse is in the united states congress. it is the house of representatives that starts. the would pass the bill on to the present. he can sign it or veto it. we appropriated the money. if you cut it, it is not an executive decision. the congress decides how much money to spend on things.

you do not need to have the president appointing with unlimited executive power. >> is the press and making appointments said it to the fis and consent of the senate. >> you can do that. >> we are doing it. >> there is a vote on the floor. >> this needs to be cleared up. we have all kinds of commissions where -- he is saying we have the power of the purse. >> the majority of this congress can create a commission which says the president can and division nominate all the

members of the commission. yes, we can do that.