opposed, no. the ayes have it. opposed, no. the ayes have it. the motion is agreed to.

>> that make it difficult to implement effective programs. we should make it easy for accomplices. it will result in healthier population and more productive work force, so i hope it will pass unanimously. >> i still think i am sitting in an invisible zone. i do want to thank the centers for working on this amendment. it does reflect common sense and promoted help the behaviors that i know will lower costs. i know that incentives work.

he was able to control health- care costs through this incentive process, and i think it is good that they brought it to us. we did it work on this in the committee in a bipartisan way. i was pleased that the senators got together with me and we made only a handful of amendments and had both republican and democrat support. i can tell you that was not the rule, that was definitely the exception. this was one of the few that passed unanimously. there was a lot of work that went into it, but sometimes unfortunate, unanimously does not mean anything. from the time the bill was voted out of the committee and the time it was reported out, which was september 17, the language

had unilaterally changed. my colleagues were never consulted, and the democratic majority staff removed that, never notified us of it. we had to discover that on our own. i think that is an outrage, any time a member or a democrat thinks that negotiating a deal on health care bill and looks carefully at what happened here, they would be upset. that is not the way the senate is supposed to work, so i hope it would get into this bill so it could be considered -- since it was adopted unanimously there, and i hope it would be unanimously adopted here. an excellent amendment that does not penalize anybody. it helps to level calls and probably cut insignificantly. a healthier, happier, more productive bunch of people, so i hope that we put in this

amendment that assures 30% flexibility. it would be nice when that person saves $1,400 and would get $700 risk benefit, not $300 risk benefit. >> just a couple of closing comments. >> i am going to paraphrasing ecclesiastes, nothing is as good as it seems, and nothing is as bad as it seems. we all talk about wellness. that is sort of the issue of the year in health care reform, more

wellness. to be honest, some of the thinking around this is not as rigorous as it probably should be. for example, one thing that comes to my mind off the top is that premium discounts, how much it will raise the premiums for those who do not participate. when those people do not participate, they may not participate for many reasons. i hesitate to say that those who do not want to participate -- if they get certification from their doctor, that they do not have to, and they also get the same premium discounts.

off the top, i wonder if the premium discounts or up to 50%, and 23% of people participate, that is a big discount. other folks cannot, but they get the discount also. what is left of the policy? it is a kind of hollowing out here. after that, we do provide a pretty significant discount. that is getting close to 1 dozen dollars per person -- $1,000 per person.

if someone cannot participate, if it is a person who has two jobs, it they cannot participate because of circumstances, i do not know if it is fair to discriminate against those people. this also applies to individual markets. frankly, what we are trying to do is reduce discrimination in the and middle-market, to prevent companies from denying health insurance based on health status. this is the inverse of that. this basically says that to be based on health status, we will give a break or penalize people who cannot participate. i am saying not just because of medical conditions, but for other circumstances.

50% sounds pretty hefty to meet. after that, a lot of health care experts say this is what we should do. chronic care accounts -- experts say it so many times, it must be true. smoking, obesity, cardiac issues, and maybe it is similar. that is true, but i ask people say at walmart, i ask why and it works at their store. the answer i got was it is partly financial incentives. more than anything else, it is cultural, the cultural ethic of that store.

if companies do work to get that cultural at the, that is great. if i am in the individual market, i can go to my insurance policy, and the policy stars to reward based on health care status, it seems to be that it's a little strange. i think certainly we should encourage wellness, there is no doubt about it. everybody loves videos. we all update ibos, safely, and so forth -- pitney bowes.

steve is a very good salesman, and i am sure that is why safeway does so well. it has such appeal, and we certainly want to encourage wellness and send a signal, but there are a lot of issues that i do not think this amendment has fully addressed. >> mac close? -- may i close? first we have to ask yourself, what with the ceo of a company like safeway spend so much time, what would they have to benefit? why would that benefit from doing this kind of program and wanting us to enact something like this for the rest of the country that would encourage

larger rewards? i ask that question just the first. his answer was, it surprised us that they were able to save so much money and change so many people's behavior based on these financial rewards, and knowing that they did this to say their company because health care costs were going to destroy their company, so he wanted to share this with the rest of the country, doing it basically as an american. he is doing it -- by the way, steve and his wife, his wife is a type 1 diabetics. she has never been to the hospital because she rick -- she really takes care of herself regularly. steve has most of his relatives who died in their 40's because of genetic heart disease.

he takes personal responsibility for his own help by making sure he each right, exercises, and takes care of himself. he is in great help. what he wants to do is try to not only change the culture as far as health is concerned at safely, but he wants to share that and encourage other individuals in the country, because he saw what was happening at safeway with health-care costs skyrocketing. let me emphasize a couple of other points. the health committee, as senator enzi said, this was bipartisan, and unanimous. we take it to 30%, and it is at the discretion of the secretary, then if they think is appropriate and is working, they can take to 50%. lastly, it cannot be emphasized

enough, we do not penalize somebody for a health condition or their health status. you do not penalize somebody for having high cholesterol. you reward them for keeping their cholesterol under control. if it is medically inadvisable for them to do any of these things, we protect them right in the amendment in legal language. it says that we have to protect them. they have to be given an alternative to meet a certain medical standard, if it is medically inadvisable to do that. mr. chairman, i think we put the protection sent, but if we really care about wellness and encouraging healthy behavior, we will adopt this amendment and a bipartisan fashion, and if we really do mean that we want to do a bipartisan bill, there is no better way to least adopt a few bipartisan amendments.

>> i might say, i agree with the concept. i think it needs a lot cleaning up, frankly, and we can clean up later. >> there is probably nobody more fit here. i suspect you are a man who runs the-mile races. when people say to me, are you encouraged that what you are doing in this bill will actually been to the cost curve? i believe there are a number of things that do significantly been at the cost curve. there are a couple of things that are not really in the bill that i find encouraging as well. one of those are rosetta a conversation i had about three weeks ago -- a arose out of a conversation that people are

graduating from medical school and trying to decide what kind of practice to go into, may be practice with the cleveland clinic or the mayo clinic. where did they want to end up? i was encouraged by the response. they want to practice in a practice like this, they do not want to have to worry about the insurance, putting up with medicare and medicaid. they want to be in a practice like this. the other thing i find encouraging is is not just safeway or kidney goes -- pitney bowes. employees are doing things to incentivized their employees. i am very much encouraged, and i want to encourage more of that. think about the number of times

we have had people say to us, i know i should stop smoking. i have tried to do it before, but i always go back. i know i should stick to my diet. i know i should do that, i have a gym membership, i know i should walk. i know i should do all those things, but i do not do it. we want to make sure they have a good financial and economic incentive. not only should to start those things, but he should stick to them. i am sure, we have a better way to ensure that that happens. >> mr. rockefeller. [roll call vote]

[roll call vote]

>> if the amendment carries. >> mad take one moment to thank the senators for their leadership on this. i did not speak up during debate because i did not want to jeopardize its passage, but i do complement you. >> could i change my vote? [laughter] >> is a testament to a lot of hard work. i know senator ensign has worked on this for a long ball, long time.

-- a long, long time. >> thank you, mr. chairman. i do have an amendment, this is a modified amendment that would ask -- direct the secretary of health and human services to convene a working group of experts in emergency care in patient critical care, hospital operations, to focus on issues around emergency room care. i had raised what seems like a long time ago concerns about what is happening in our emergency rooms, and the fact that our emergency room doctors in many cases are primary care doctors right now. i would like very much to see us address that as it relates to payments incentives for

emergency room physicians. this amendment does not do that, but it does do something else that is very important, which is to focus on what we know to be critical issues about patient access. it would set up a working group to recommend guidelines to ensure patient access to emergency rooms. the chairman commissioned a gao report released in june that found that patients in need of immediate care actually waited twice as long, up to 28 minutes. seven by% of the time, people had to wait longer than the recommended time -- 75% of the time, they had to wait longer than the recommended time for emergency room care. inadequate access to primary care was a contributing factor. it is important that we look at

and develop recommendations on how to address overcrowding, what is called boarding, that threatens to overwhelm our emergency rooms, and in the long run what we are doing will affect emergency rooms so that your people are using emergency rooms for primary care doctors, but it will be a few years before we see a change in that. in massachusetts, they found that just focusing on insurance alone did not resolve the problems related to emergency rooms, they need to focus on what should be done in terms of various guidelines and procedures. >> i am prepared to accept the amendment.

>> mr. chairman, i would like to call up amendment no. c-22. there has been a lot of discussion about personal responsibility on the part of individuals to see that they are covered, and we have heard from senator carter and senator innocent about the importance of personal responsibility in taking care of yourself -- center carter and senator in andensign. this the men and make sure that this principle of personal responsibility applies to every american, including those who are on medicaid. i have shamelessly borrowed from the west virginia provisions which have been implemented a few years ago towards the medicaid population.

all it did was ask these beneficiaries receiving public dock forced to do things that would keep them healthy -- receiving public dollars. number one, i will do my best to stay healthy. number two, i will show up on time and i have appointments. this is one reason i have heard from dr. -- doctors in texas what they will not take medicaid patients, because they do not show up on time, or when their appointments are scheduled, so this seems like a logical one. i will use the emergency room only for emergencies. we know this is a huge issue, the least efficient and most costly means of delivering care. if we can find ways of encouraging medicaid beneficiaries to see clinical care and stay out of the emergency rooms were possible, that seemed like a good thing. finally, i have a right to decide things about my health care and health care of my children, and last, i will be treated fairly and with respect.

i think promotion of this principle of personal responsibility is not controversial and something we can agree on, and i ask my colleagues for their support. >> i did have a question. earlier in the day, i believe it was you that brought the ec b m recognized it had an $11 billion error in a scoring. it was not their fault, but it was clearly something that had to be reject. we reject it, and it turned out to be $11 billion. i would just like to ask you a

question about it. it seems to me that that is one reason why we should have been acted the bunning amendment, but be sure we are right on the scoring. that is one reason why i think maybe -- it does not seem like we are rushing it, but we are rushing this. who knows how much other scoring is going to be off? just want to know if you feel that is a very important issue. >> certainly. we have seen a number of mistakes on scoring because of the problems as the doctor said, they going at maximum safe speed, we have seen an erroneous corps initially on mine sgr amendment, it was initially scored at $10 billion more than

and ultimately ended up being scored, and this other one involving the agreement of the american hospital association for a certain price to be excluded from provisions of the pedpack steroids provision, where essentially that entity will not be able to cut -- may cut that it deems necessary because of the deal. so yes, i am concerned about it. i agree with you that the bunning amendment should have gone along with that. members need to know whether or not this new analysis will have a negative them picked -- impact on spending. i suspect it will. also there is a $100 million mistake -- the reason i raise this is because another is a

real desire to get this sent over. no one has the desire more than i do, but i wonder if we are not pushing this to the point that we are not getting were we ought to get. i guess we have to finish this process before the cbo can literally do the scoring for the whole process. i hope that once we are finished in this markup that the committee will allow cbo enough time to score this thing before it goes to committee. we ought to know what we are voting on and what the costs are. frankly, i am really concerned about it. i have been thinking about this all day, and i think cbo has been under tremendous pressure by all of us. i think they do a great job and

i have a lot of confidence in them. that this morning was almost more than i thought could happen during this process. i am hoping that once we get through this markup that we will have time to give this cbo enough time to really look at what we have done and tell us what the final economics of the matter really are going to beat. i do not think we are doing what is right for the population at large or for ourselves if we do not get that kind of information. i wanted to just bring it up all center corner and was doing his amendment, because he raised this morning -- call center corner and was doing his amendment. -- while senator cornyn was

doing his amendment. it was actually $600 million. these are not inconsequential things, and i am just very concerned about it, and i wonder if my colleagues are as well. >> we have discussed this many times. let me say as i have said many times, it is my intention that we will get a score on this bill before we finally vote on its. it may take a few days, once we finally wrap up what we agreed to hear, or the majority agreed to hear, and then send that to cbo. it might take a few days to get the score before the final vote, but it is my intention to get the score before we have the final vote. >> mr. chairman ask a question on that?

you are aware that -- of the news stories on this. do you think there is any additional legislative amending or change in your mark that needs to be done to effectuate the policy that you intended? if not, with the cbo -- what assumption with the cbo be using with respect to this so-called car out so that they could take into effect what it is the authors of the mark intended? >> the cbo will score the bill as they read it, and they will use their objective, neutral, unbiased, and fair and balanced judgment. >> in it would be your view that

there is nothing necessary by way of amendment to clarify it? >> someone could find some ambiguity some place. i think it is wise to let the cbo work with what they have. >> will it be done on a conceptual bill, or will it be done on a final draft? >> it will be conceptual first. at one point he said it would take two weeks to soref, and i do not know if we have two weeks -- too weak to score it. we will give him time, several days, to score this bill, as we customarily have in the past. we will give him sufficient time

to do his preliminary analysis, and my guess is scoring on natural language might not be that different. we have to merge the two bills, too, and i think we will be working on the scores while we are merging the bills, but we will have a vote after cbo scores the modified mark as amended. i guess about three days, and after the three days, we will get a vote on the bill. >> based on the story this morning, about this hospital carve-out, was a clear, or not clear?

why was there a question by cbo with regard to that? was it clear from our stand parpoint? i think that is important here. i think it is a good example of the problems that we could potentially face, and i remember this summer we had errors are miscalculations are under estimations of more than $70 billion, so i think it is important that we learn from this experience and the specific instances. >> i think there was ultimately a bit of confusion that we

realized ultimately after the mark was released. we talked about how to handle this issue, and we were going back and forth on it. ultimately we made the decision that a language does result in a carve-out, but i think cbo was left with the impression that what we said it clearly indicated. much after the fact, we realize that maybe it did not reflect it, and from their perspective there are still looking at it. >> there has got to be clarity in these policies. >> that is my intention. we are working with cbo to achieve that clarity. >> we will -- will we have the opportunity as a committed to respond to some of these issues before the final vote?

>> i have no doubt it will be fair about this. this is one sixth of the american economy. if we do not get it right, i cannot tell you the repercussions we are born to have in the future. -- we are going to have in the future. i do not see any reason to overly rush this, and i agree, i guess you have to meld it somehow with the health bill. having lived through that marked as well, i think it is really important to give cto enough time to really be able to tell us what is going on here, and hopefully in a competent manner so that we did not have to keep coming back to it and revisiting yet again and again.

this is an important issue, and had we agreed to the bunning amendment, we would be a lot farther down the line and we would have a lot more confidence in what is going on here. i know you intend to do a good job here, but i do not see how you can expect cbo -- all of the language we have and we have had to discuss back-and-forth, and we are hardly denting the conceptual language that is brought here. we are giving them almost an impossible job, and you say you are just going to give them a few days to be able to come up with some sort of answer before we vote in committee. >> i will wait until you finish. >> i will just take another

couple of sentences. look, i think cbo has a very, very difficult job. i do not think we have been all let helpful to cbo with some of the things we voted upon, positive and negatively. i have a desire to help them be able to have every ability they can exercise to get this job done right. the way i have interpreted what you have said, we will finish the conceptual market. they will then score that within a certain number of days, and then because of the health committee bill, there'll be some work to resolve the conflicts between the two bills, and then hopefully, that will come up with the final legislative language, which cbo says will take them at least two weeks to

do this, and it may take them two weeks or longer to do the final statutory language. i just want to make sure i understand this process, because i am very concerned about that. we can hardly say we are rushing this, but i think we can be too concerned about not giving enough time. >> actually, senator, that is not what i said. i said that when we finish the bill, we will then give the bill to cbo. >> the conceptual bill. >> the conceptual bill to cbo, which the committee has done for more years than -- i might add, this is along this markup in 15 years. cbo has told ume that they need

about three days, and that will give us their preliminary score. we then vote on the bill. it may be that the preliminary score is not deficit neutral over 10 years, as is required by budget legislation. that is the case, we will have to modify it. there will be modifying amendment. i am not quite certain how long it will take the cbo to then score that. my hope is that if they tell us where up out of balance, that they can tell us how and why, so it can be remedied very quickly. that would then give us a ruling that we are deficit neutral. then we have to merge the bills, after we vote.

i want to vote on this bill first, before there is any merger. in talking to the leader, he would like to move this bill after we get a score. i talked to him about that just a few hours ago. after we get the score from cbo, not before. he therefore expects us to vote on this bill sometime this week. he then begins the process of merging the bills together. to be honest, i do not quite know what he has in mind. i know he has been talking to cto and has for some time to try to work with two committees to get a score on the bill before is brought up on the floor of the senate. it is my view that we need to have a ruling by the cbo before

we go. it is also my view that we need a cto ruling before we go to the floor on the first bill. -- on the merged bill. to be candid, he may not like this, but i do not think we can wait around for two weeks. if there is a problem later on -- i do not expect it will be that different. on a more narrow issue, working with cto on the medpack issue to get the scoring that we hope to get on the division, if it turns out that cbo says we have to

come back to get the scoring and savings would want to get on the amendment. it is in hands of the cbo at this point, and we just have to do our best to be totally open and transparent. >> mr. chairman, i have served on this committee a lot of years and on the budget committee my entire time in the senate, and i know there is a concern. i have talked to some colleagues, both sides of the aisle, about what happens if there is a discrepancy between the bill as written in plain english, which is the way this committee considers legislation , and the legislative language which is to follow.

i was in conversations with cbo, as was the chairman, in which they seaid they would need two r three days once we are done here to provide us a score. that would be before they take the legislative language and prepare another score. the concern i picked up from a number of colleagues is, what if there is a discrepancy between the bill as written in plain english, so all of us can understand it and our constituents can understand it when it is on the website, and the legislative language? my experience has been, and i would ask the chairman if it is not his intention, that if there is a discrepancy between the score on the bill written in plain english, which is what we would vote on, and a score provided by cbo, and a

subsequent score based on the legislative language, that if there is a discrepancy, my experience has always been in this committee that the chairman addresses that in a manager's amendment to recapture the intention of the committee and they pass the bill. is that the chairman's experience? >> absolutely. it is almost amazing to me how all that has worked in good faith. every chairman i have served numbeunder has done that. it makes no difference, and in good faith we always distrust each other. that is exactly right. it has always work seamlessly. i have never seen anything even

close to being characterized as heavy-handed. it is always transparent and in good faith. how does want to praise you. i just want to say something nice about you. i do not think anyone would doubt that you act in total good faith. but the fact of the matter is that there will be a subsequent bill when you work with the help committee which is an entirely different matter. they do not do it this way. they do it, as i recall when i was chairman, they do it on a full score legislative language way. you can see why i am concerned

about the process here of how we handle this. i don't think the one doubts that it is in a very good faith manner. i want to raise these procedural issues because they are tough issues. will the general public and everybody be given at least three days on the internet to read it and look at it and see if there are any mistakes that we can come up with? >> as i said, when the cbo gives the store, then we will have an opportunity to vote. >> i just want to bring to the chairman's attention that the help bill, and i went down and talk with the ranking member, passed the committee on july 15 with three titles not in

legislative language, and no score. the bill was sent to the floor of the u.s. senate on september 17 with legislative language, and still no full score. so they never got a final score prior to voting on the bill. i just want to make sure that this committee does not try to do that, and then after its final passage, the merger of the two bills, we cannot have one conceptual and one in legislative language to get a final score on a merged bill. so what is the chairman's intention at that time?

>> first ball -- first of all, we can only control what we can control. there are certain areas we cannot control. we can control to some degree our committee. it is difficult to control other committees. we will do our very best to get the score. we are not going to vote on the final bill until we get the score from the cbo. then the next debt is to merge this bill with the help committee bill. that is up to the leader. i do not know what his plans or intentions are, by suspect he wants to move without too much delay. >> could you give us some assurance that we are at least going to see a final, merged bill before we vote on it?

>> i cannot give a total insurance, but that would be my wish. >> a quick question. will we have decision time to review the mark after it has been scored? >> it will certainly have time to be the mark walt cbo is reviewing the mark. -- while cbo is reviewing the mark. >> i hope we do not get it at 9:00 and then we are voting at 10:00. >> that would not be in good faith. >> i think you have answered the question i was going to ask, but i want to be clear. i was going to ask in the process you describe, whether we would have bill language at the time the health bill and the

finance bill are merged, and i understood you to answer that question by saying that you would expect that that should be the way we should do it, but you could not control it. >> that is right. i cannot control the health committee. -- the help committee. >> as chairman of the finance committee, if we work for a year to vote a bill out, we ought to be able to see the product that we produced. if you are telling me that we might not see a statutory legal language in the product, then i think, what are we wasting our time here for? so we ought to have to products, one from the health committee, one from this committee, and at that point, somebody in the senate above us decides how it is going to be done.

>> senator conrad is recognized. >> i had not concluded my thought. my point was that, from the answer you gave, it sounded to me like there was the possibility that we could yet again after this committee had concluded its work be facing a circumstance when, after the two bills were merged, that we had been converging -- we had been merging eight -- we would still not have an opportunity for the members of the senate at that point to be able to observe that legislative language. i just wanted to make a point that the circumstances that came up today with regard to the cbo score on the pedpack language is an example of the concern,

namely that the conceptual language led cto to believe that a hospital deal was not included, but the hospital deal was supposed to be included, and when it cbo figure that out from the conceptual language, they indicated they had a $10 million mistake. my point is to say that that is an example of what many of us are concerned about happening, and that is one of the reasons why we like to get some kind of certainty with regard to when there will be statutory language. >> let's go to the amendment. i intend to operate entirely good faith, all the way around. to be honest, i do not know if we can wait two weeks for the legislative language. in fact, it might take longer, given the experience of cbo, but we will operate in total good faith. we will get the cbo's corp.

after we complete our business here, we will look at the score, and we will operate in good faith. i will do all i can to make sure that we get the score on but merged bill -- on the merged bill, so that people have an opportunity to see what is in the product and what is not in the product. >> we are a democracy. we are an imperfect institutions. we try our best. we work hard, but the real clue here -- the real glue here is to operate in good faith. if both sides operate in good faith, and we are doing our

business, the senators can vote any way they wish to vote. all i am saying is we will do our very best to operate in good faith and give the centers the opportunity to review the bill. >> isn't the case that when there is a merged bill, it comes to the floor, by definition, it will have to be in legislative language? >> that is correct. but so what we have is what we have always had. maybe it is because other members have not been in chairmanship's or not gone through the hoops here, but the path here is one well-traveled. this is not something new. the pattern is very clear. you have the bill that is

recorded here in plain english. it scored by cbo. the chairman has said very clearly will not vote until there is a score. then the plain english is translated into legislative language. that will be several weeks before cbo has a score on that. by definition, the bill that goes to the floor that is a merged bill between the two committees of jurisdiction has to be in legislative language. it has to be. and so that will be the bill for all to see, for all to read, for all to evaluate, and that will be scored. that will be scored. >> my concern -- it is like cool hand luke, we have a failure to communicate. my concern is obviously in reconciling the scoring and we

have the legislative language and all that that has been talked about with my colleagues. i guess i did -- i just did not get it until i read the press articles about this. here we have the assertion that the american hospital association made a deal, if that is the way to put it, or at least to agree to $150 billion worth of cuts, and then made an additional deal with somebody and said but, we are not going to take any additional cuts -- i do not know if that is the first year after this or the next year. i do not know how this figure was reached, $11 billion separate that would be recommended by the medicare commission that senator rockefeller spoke so strongly for, that would be immune to this kind of deal. it would mean that the medicare commission has already succumbed

to the hospital lobby, saying we gave $150 billion up front, we are not going to give any more to the tune of $11 billion, and that that is really responsible for the carveout efficiency, and that is the case, it speaks to what senator rockefeller was trying to do, and it speaks to the fact that deals can still be made, because obviously if it is the aha or anybody else, how they can come here and lobby and still, despite senator rockefeller's efforts, by past that. i would like to know if that, in fact, is correct, and who is responsible for the carveout for $11 billion? >> ok, let's go to the amendment. >> i have been patiently waiting.