Max Baucus

Mr. BAUCUS

Mr. BAUCUS. An example of that. I was talking to the head of Denver Health. It is an integrated system. I have forgotten the name, but she was so enthusiastic about the integration she performed with Denver Health. I will give you one small example, and it is one you just mentioned. She said: We have patients here--heart patients--and when they are discharged we ask them: Are you taking your meds? Are you controlling your blood pressure? Are you taking your medication to control your blood pressure? They say: Oh, yeah, yeah, yeah, I am taking my meds. She says: Well, why is your blood pressure so high? The response is: Well, I, I, I. Because they are integrated, they check with their pharmacy, which is part of their system, to check the refill rate of the patients. Sure enough, they find their patient's refill history shows they were not taking their meds. So they get the patients back and they say: You are not taking your meds. They say: Oh, I guess I wasn't. They tell them: We are checking on you. So, sure enough, they take their meds, and they have a much better outcome, generally, with their cardio patients because of that integration.

Mr. BAUCUS. Absolutely.

Mr. BAUCUS. I don't know how much longer my colleague wanted to speak, but some time ago I know Senator Hatch wanted to speak at 5 o'clock, so I am trying to be traffic cop here.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, today I wish to speak about the life lessons we learn from participating in athletic activities and from the coaches who teach our young athletes. Michael T. Powers, author of many inspirational books once said, ``High school sports: where lessons of life are still being learned, and where athletes still compete for the love of the game and their teammates.'' High school sports are a way of life across Montana and they create an important sense of community in small towns and cities all over Big Sky country. In many areas across the state, small high schools will pool their resources to field football teams each fall; many play six or eight man games. This year Ed Flaherty, a native Montanan co-authored the book ``Coached for Life'' about the experience he and his teammates had on the State champion Great Falls Central High School football team in 1962. I was inspired by the stories of these young men and how the lessons learned on the field from their coaches shaped who they became as people and their experiences later in life. The young men that made up Great Falls Central's 1962 Championship squad truly embody the best of Montana ideals and values, like hard work and taking responsibility. They labored tirelessly both on and off the field and achieved not only athletic glory, but also learned the value of a good education and how to be role models and ambassadors for their school. Great Falls has always been a working class town and many families made significant financial sacrifices to allow their children to attend Great Falls Central, a private Catholic school. Coaches Bill Mehrens and John ``Poncho'' McMahon, reminded the players each day that playing football at Central was a privilege and that they had a responsibility to their teammates, their school, and the community to give it their all on each and every snap on the practice field, in the game, and in the classroom. No doubt the coaches pushed these young men each and every day, they did it to instill discipline and to make them the best they could be. The 1962 season was a special one for Great Falls Central. The goal of the team was to win the State championship. A year earlier, the coaches drove some of their players north 115 miles to Havre to watch the State championship game, not only to scout two of the best teams in the State but also to witness a championship win. The Central players took it all in and knew they wanted to be the ones holding up the trophy the following season. The Mustangs achieved that goal, making it through the 1962 season undefeated and beating their rival, the defending State champions, Havre High 34-6 in the Montana Class A State championship game in front of more than 5,000 elated fans on their home field. Having gone through this experience, the men later in life were able to rise up against the many challenges that were thrown their way. At a team reunion in 2002, 40 years after their championship run, the players and coaches got together to reflect and share their life stories. Some have gone on to be teachers and coaches, passing on the life lessons they learned from Mehrens and McMahon. Some, like Ed Flaherty, have achieved successful careers in business and in turn gave back to their communities. Some served their country heroically in the military. All have taken the lessons they learned from the fall of 1962 and have helped their communities and become leaders. Ed Flaherty has compiled these stories in his book and brings to life that amazing season and what it truly means to be coached for life.

Mr. BAUCUS

Mr. BAUCUS. Madam President, I yield myself 1 minute. Very much straight to the point here, there has been some discussion about CBO's assessment on the health care premiums. The letter was out yesterday. That letter shows that for all Americans--all Americans--premiums will be lower. They will be modestly lower to those larger employers. We have a range between those small businesses of between a 1-percent reduction and a 2-percent increase, and for the individual market there is more variation because there is much more variation today currently in the individual market. Those who purchase in the individual market will be getting a lot better quality of insurance than they are getting today--much better. About 60 percent of those in the individual market will find that their premiums are actually lower after the tax credit/subsidies are taken into consideration. So netted all out together, all Americans are going to see their premiums are lower for what they get today. About 7 percent will see an increase, but they are getting better coverage than today--quite a bit better coverage. On a net basis, basically, bottom line, everyone were will see his or her premiums lower. For the 7 percent that are not lowered, they will get a lot better quality of insurance. That will more than offset the increase in premium. That is what that CBO letter says. I urge all folks who are interested to read that letter. I have one other minor point on the so-called Cadillac plans. CBO said that those who receive Cadillac plans will find their premiums reduced, not increased--I think it is by about 6 or 7 percent. That, too, is very important. There has been a lot of discussion about the effect of premiums on Cadillac plans. CBO says those premiums will be reduced. My minute is probably up. I wish to use the last seconds to just say that the net, all the way across the board, CBO says premiums will be reduced when you take subsidies into consideration and compare the plans people get today with what they would otherwise get in the future, the quality of coverage.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, I ask unanimous consent that the next four Republican speakers to be recognized be Senators Johanns, Roberts, Hutchison, and Cornyn and for the Democrats to speak in an alternating fashion, with the next Democrats being Senators Murray and Cantwell to speak on the tragic shootings in Washington, and that following Senator Roberts, I be recognized.

Mr. BAUCUS. I am sorry. I think Mr. Roberts is to be recognized.

Mr. BAUCUS. Mr. President, I wish to once and for all lay to rest this false claim that the pending bill is going to ``hurt seniors'' and is going to hurt providers; it is going to be this long parade of horribles that the other side likes to mention. It is totally, patently untrue, the claims they are making. No. 1, all the crying allegations on the other side that the underlying legislation cuts Medicare, it cuts Medicare, it cuts Medicare--that is what they say. What they do not say is it does not cut Medicare guaranteed benefits. It doesn't cut benefits. It does reduce the rate of growth that hospitals would otherwise receive. It does reduce the rate of growth that medical device manufacturers might receive. All that is true. So it is true it is cutting the rate of growth of Medicare providers. It is not true that this legislation cuts Medicare benefits. That is not true. The other side would like you to believe that is true by using the words they choose. By saying ``cutting Medicare,'' they want you to think that is cutting Medicare benefits. But it is not cutting Medicare benefits. Rather, the underlying bill reduces the rate of growth of government spending on providers, on hospitals, home health, hospice--lots of other providers. That is what is going on here. Don't let anybody fool you. This bill does not cut Medicare benefits. It does not. But it does reduce the rate of growth of providers. Why are we doing that? First of all, most of these providers, virtually all the providers say--gee, we don't like our rate of growth, the Federal dollars coming to us, cut, but they will go along with it. They are OK with it. Why are they OK with it? Why is the American Hospital Association OK with reducing the rate of growth of hospital payments by $155 billion? Why are they OK with that? They are OK with that because they are going to make it up on volume. This legislation provides coverage for many more Americans. They are going to have health insurance. Americans who do not have health insurance now often have to go to the emergency room of the hospital, the hospital has to provide the care, it is uncompensated care--nobody is paying for those hospital benefits--and that cost is transferred on to private health insurance premium holders. They have to pick it up. On average, that is about $1,000 per family per year. No. 1, let me repeat, there are no cuts to Medicare benefits. There are reductions in the rate of growth to Medicare providers--which the providers agree with, by and large. I won't say totally, I wouldn't stand here and say they are jumping up and down and they are enthusiastic about it, but I am saying they realize they are not getting hurt. They are going to do OK. They are going to do OK because they are going to make up in volume what they might otherwise lose. That is a very important point for people to understand. Second, if you listen to the other side, what they would have us do is virtually do nothing. What does doing nothing mean? Doing nothing means the solvency of the Medicare trust fund is just over the horizon. This legislation extends the solvency of the Medicare trust fund another 4 to 5 years. Man, if I am a senior--I am about to be a senior--I would sure like the Medicare trust fund to be solvent. I would like that very much. This legislation extends the solvency of the Medicare trust fund by another 4 to 5 years, to about the year 2017. So without this legislation, the actuaries say the Medicare trust fund is going to become insolvent 5 years earlier, 2012, somewhere there. That is not many years from now; not many years at all. So it is very important we extend the solvency of the Medicare trust fund. You might ask why is the Medicare trust fund in a little bit of jeopardy? Why is that? The very basic reason is because health care costs are going up at such a rapid rate in America. Our health care costs are going up by 50 or 60 percent more quickly than the next most expensive country. We already are paying per capita 50 percent or 60 percent more than the next most expensive country. So there is a whole host of things we are doing in this legislation to make sure we have some limit over our health care costs. I realize I misspoke earlier. Currently the Medicare trust fund is due to be insolvent about the year 2017. This legislation extends the solvency of the Medicare trust fund to the year 2022. The principle is the same, just the 5 years is tacked on a little later period of time rather than upfront. But we are doing a whole host of things in this legislation to reduce the rate of growth of health care costs to people in this country. It is health care costs which are driving up the Medicare trust fund costs so we are doing all we can to extend the solvency of the Medicare trust fund. People are saying the Medicare trust fund is getting insolvent because baby boomers are retiring, and that will increase the pressure on it. But the Congressional Budget Office did a study 6 or 8 months ago that said about 70 percent of the additional cost of the Medicare trust fund is due to cost increases, it is not due to more baby boomers retiring when they reach the age of 65. What do some of the groups say about this legislation? Let me say what AARP says. We have a chart here which indicates what the American Association of Retired People says about the underlying bill. If it was cutting Medicare as the other side says, you would think they would not like this bill. You would think they would have problems with it. AARP has not totally endorsed this bill, but they don't have problems with it because they know we are doing the right thing. What do they say? AARP says: Opponents of health care reform won't rest. [They are] using myths and misinformation to distort the truth and wrongly suggesting that Medicare will be harmed. After a lifetime of hard work, don't seniors deserve better? That is what the AARP says, referring to the distortions, misrepresentations, and untruths, trying to scare seniors, mentioned by opponents of this legislation. Here is another AARP quote. This is this month: The new Senate bill makes improvements to the Medicare program by creating a new annual wellness benefit, providing free preventive benefits, and--most notably for AARP members--reducing the drug costs for seniors who fall into the dreaded Medicare donut hole, a costly gap in prescription drug coverage. That is a very important point. This bill not only does not cut benefits, it increases benefits for seniors. A big one is referred to right there and that is the so-called doughnut hole, the gap in coverage under the prescription drug program. This legislation in effect says that seniors now who have $500 of their drug benefit, prescription drug benefits paid for when they are in that doughnut hole period, and add to that this bill also says it is all paid for, at least for 1 year, in this doughnut hole. We have to worry about that in subsequent years, but this bill improves the benefits that seniors will get, not take away benefits as the other side would imply. It is true that private programs, such as Medicare Advantage, are reduced from what they otherwise would be, just as hospitals are reduced in payments from what they otherwise would get. I have a chart here. Let me point out the next chart here, if I could, which shows that the provider groups, hospitals, et cetera, are actually going to do OK under this legislation. What does this chart show? This chart shows that Medicare spending will continue to grow under this legislation. It will grow, and grow by a lot. Here, in 2010, it is $446 billion and you see a steady growth through the 10 years of this bill. I might say parenthetically, one of the previous speakers said rural health care is going to be hurt, rural hospitals are going to be hurt in this legislation. I do not think that is entirely true. I have a lot of hospitals in my home State of Montana, rural hospitals. They are not upset with this legislation. They say it is OK. They approve it. In addition, there are no cuts to critical access hospitals. In rural America most of those hospitals are critical access hospitals. So they are going to be OK. Basically, if we did not pass this legislation, these provider groups--hospitals, nursing homes, home health, hospice, Medicare Advantage, even Part B Medicare improvement--would all increase by about 6.5 percent over the decade. Under this legislation they all increase by about 5 percent over this decade, with a 1.5 percent cut which they basically agree to. I want to make that point clearly. We are not cutting Medicare. We are not cutting Medicare benefits, but we are reducing the rate of growth of Medicare spending. Another point I want to make, if I may, is there is nothing new here. Many of the Senators who are advocating killing this bill made the opposite statement not too many years ago. What did they say? They said: You have to reduce the rate of growth in Medicare spending in order to save Medicare benefits. That is what they said a few years ago, exactly what they said. Let me read: We propose slower growth in Medicare. Medicare would otherwise be bankrupt. They are standing on this floor making the opposite statement today, the exact opposite statement today, trying to scare people to kill the bill. Here is another Senator. I will not embarrass them by giving their names, but they are Senators who currently serve in this body. We do heed the warning of the Medicare Board of Trustees and limit growth to more sustainable levels to prevent Medicare from going bankrupt in 2002. That is what is necessary to ensure that seniors do not lose their benefits altogether as a result of bankruptcy in 7 years. One Senator said that. When? About 14 years ago. Exact same thing that is going on today. We know, experts know that if we are going to save Medicare benefits, we have to stop overpaying some of the providers, hospitals and so forth. We are overpaying them. Let me tell you one small example of how we are overpaying them. Did you know that the updates--the fancy term for paying more for hospitals and so forth--did you know they don't take productivity into account when they make these update recommendations? The recommendations are basically made by an organization called MedPAC. MedPAC is a nonpartisan organization composed of doctors and experts that advise Congress on what the payment updates--what the payment increases should be for different groups over the years. We in Congress basically look at them. We try to decide what makes sense, what doesn't, and so forth. But MedPAC has said that this is what we have to do. We have to slow the rate of growth in some of these providers because they are getting paid too much. They are getting paid more than they need to be paid. I repeat: We are still going to allow 5 percent growth for all the providers over the next 10 years. None of them are really crying wolf, I might say. That is the main point I wanted to make. I mentioned what AARP is saying. Let me mention the American Medical Association: [We are] working to put the scare tactics to bed once and for all and inform patients about the benefits of health reform. That is the American Medical Association. They are referring to the scare tactics of the other side. The AARP and the American Medical Association and others know that no senior will see a single reduction in their guaranteed Medicare benefits under this bill, not a single one. I might also say that this bill would reduce premiums seniors would have otherwise paid. Much of those savings to seniors comes from eliminating massive overpayments to private insurers; that is, private companies such as Medicare Advantage. A small point here. When seniors hear the words ``Medicare Advantage,'' they tend to think that is Medicare. It is not. It is a private company. Those are private companies. They were basically enhanced. Under the 2003 Medicare Part D legislation, they were given a lot more money to encourage them to have competition in rural areas. It turns out we gave them way too much additional money. They know it. This legislation is trying to cut back on the excess they were provided back in the year 2003. The cut is about $118 billion over 10 years. I don't have with me how much is remaining. But that 5 percent figure I gave you of growth, that includes Medicare Advantage. I mentioned already that this legislation would reduce prescription drug costs. That doesn't sound like a benefit cut to me; that sounds like an additional benefit for seniors. We also provide for new prevention and wellness benefits in Medicare. That is an addition. That is not a cut. That is an addition. We are also helping seniors stay in their own homes, not nursing homes. That is a benefit. It is important to point out here that the opponents of health care reform do not have a plan to protect seniors and strengthen the Medicare Program. They say don't do what they said a few years ago. They say: Commit the bill, do nothing. They say: Go back and start from scratch again. That is basically what they say. If you listen to the music as well as the words, if you read between the lines, basically they are saying: Kill it. Don't do it. That doesn't make sense. That is what they are saying. I hate to say this because I tend to be a pretty nonpartisan kind of a guy. But these are scare tactics. They are not truths. Sometimes you have to call a spade a spade, and that is exactly what is happening here. I might say that MedPAC, the outfit that advises us, is nonpartisan. They can't help us decide what to do here. They think Medicare Advantage plans are overpaid by 14 percent. In addition, a typical couple will pay $90 more per year in Part B premiums to pay for Medicare Advantage overpayments even if they are not enrolled in these plans. That is not right. Medicare home health providers--I gave that list earlier. One small part of that is Medicare home health providers. They have an average margin of 17 percent. That is a little high. If we are trying to protect Medicare benefits, we have to make sure we are not overpaying the Medicare providers. That is just common sense. It is the right thing to do. So many seniors just need help with their Medicare benefits. Nursing homes are making profits of 15 percent off of Medicare. In my judgment, that, too, is unacceptable. We have to bring those down within reason. We have an obligation. This is a government program. We have an obligation to taxpayers to make sure we are not overpaying hospitals and providers. We have to do right by them, make sure they are doing OK, but just not overpay. That is a tough line to draw sometimes. It is a judgment call. But that is what we are doing here. In addition, the Office of Inspector General has found rampant fraud and waste and abuse in the Medicare Program. There is a lot of fraud and waste in the Medicare Program. The last figure I saw was about $60 billion in fraud in Medicare--providers, frankly, just ripping off taxpayers and seniors. We have added additional provisions in here to outlaw that fraud--additional screening, additional certification, additional ways to make sure that Medicare does a better job, that CMS does a better job in knowing which payments to providers are right and which are not right. What is the real impact of the Medicare policies here? Let's be clear: The real impact of these policies, even with the Medicare changes in the bill, overall provider payments will still go up. I don't want to beat that horse too much, but I want to make it clear. We are not cutting benefits. We are reducing the rate of growth of spending for health care providers, hospitals, and nursing homes, but we are reducing it in a moderate way. We are not reducing it by too much. As this chart shows, those providers still get at least a 5- percent net increase in payments over the years, and the groups themselves have not really complained about them. Take the pharmaceutical companies, hospitals, nursing homes, home health, hospice--they are not crying crocodile tears because they know they are going to do better under health care reform. Remember that famous meeting down at the White House not too long ago. The industry came in and talked to the President. Remember what they pledged, all these providers, how much they can cut reimbursements to them? This is including the insurance companies, hospitals, and everybody. They said they would cut $2 trillion over 10 years--$2 trillion. This legislation doesn't come close to cutting $2 trillion. I think the figure is about $400 billion. That is not $2 trillion, that is $400 billion. So we are not hurting them that much. We are not hurting them, frankly. They are doing OK. I have quotes from hospital associations. This is from Sister Carol Keehan, president of the Catholic Health Association: Clearly, the Catholic Health Association thinks the possibility that hospitals might pull out of Medicare . . . to be very, very unfounded. I have heard the claim over here that this legislation is going to cause providers to pull out of Medicare. That is totally untrue. I have so many quotes here from people in the hospital industry who believe this is OK. They are not going to pull out. Chip Khan, president of the Federation of American Hospitals: Hospitals will always stand by senior citizens. I also know some providers are going to do very well under this reform legislation. Wall Street analysts have suggested that many providers, including hospitals, will be ``net winners,'' according to the basic feeling among Wall Street analysts. Under our bill, they estimate hospital profitability will increase with reform because more and more hospital patients will have private health insurance. Nobody is going to pull out. They are not going to cut Medicare benefits. It is true that there is a reduction in some of the private plan nonguaranteed benefits companies would give to seniors at the expense of private patients. That is true. MedPAC has said it should be cut. MedPAC has said it should be cut more. We are giving these plans a break by not cutting them by what MedPAC says they should be cut. Again, the reductions in this bill--for the providers, not beneficiaries--are far less than the health care industry itself said it could save over the next decade. A reminder: They pledged to save $2 trillion over 10 years. Under this legislation, they are going to be hit for $400 billion. I mentioned before that the other side has often said this is exactly what we to have do, although today they say: No, no, no. I am not quite sure what the difference is between a few years ago when they said this is what we should do. Perhaps they can explain that. I might mention, too--and this is very important, although we tend to lose sight of it--under this legislation, we provide delivery system reform. There is a lot of waste in our health care system--estimates are 15, 20, 30 percent waste in the American system. Why is there so much waste, which means seniors are not given the benefits they should receive, which means private patients generally aren't getting the benefits they should receive because of all the waste? The waste is basically because of the way we pay for health care. We pay on the basis of quantity. We pay on the basis of volume. We do not pay on the basis of quality. To state it differently, a hospital tries to do the right thing, doctors try to do the right thing. They are paid on the basis of how many procedures they provide, basically, not outcomes, not quality. That is the basic root that has caused a lot of the waste in the current American system. Health care is provided for differently in different parts of the country. The fancy term is ``geographic disparity.'' Health care in one community is practiced one way. Health care in another community is practiced another way. They are very different. Many of us have read the June 1 New Yorker article written by Dr. Gawande comparing El Paso, TX, with McAllen, TX. I see the two Senators from Texas on the floor. Perhaps they can help us elucidate what is going on in El Paso and what is going on in McAllen. In El Paso, the cost of health care is about half per person what it is McAllen, another border town. Spending per person in El Paso is about half what it is in McAllen. Yet the outcome; that is, how well the patients do, is a little bit better in El Paso than it is in McAllen. Why? According to the author of the article, it is because of how medicine is practiced, what is the ethic, what is the sense in El Paso regarding health care and what is it in McAllen regarding health care. It may be dangerous for me to say so, but according to the author, his conclusion is that in El Paso, it is because the care is more patient centered, it is coordinated care, it is less on making a buck; whereas in McAllen, it is less coordinated care, more specialties in hospitals, a little bit more providers wanting to go make a buck. The main point is that medicine is practiced so differently all over the country. There are geographic disparities. In Northern High Plains States, it is less spending per person and the outcomes are terrific. In some of the Sunbelt States--and I don't want to step on the toes of any Senators from Sunbelt States--there is more spending and the outcomes are worse. It is just because it is based on volume and quantity, not based on quality. This legislation starts to put in place ways to move toward reimbursing based on quality, not volume. That, paradoxically, is going to result in lower costs and higher quality--lower costs but higher quality. Virtually all the folks in the health care community--the doctors, hospitals, and administrators I talk to--virtually all agree-- I will be very conservative--80 percent agree, 85 percent agree, this is the direction in which we have to go. This legislation goes in that direction. Failure to pass this legislation, which the other side wants, means we do not do any of that. It means we do not start putting in place ways to more properly reimburse doctors and hospitals and other health care providers. This bill includes those patient-centered reforms I just mentioned. What are they? They include accountable care organizations, bundling is another concept, reducing unnecessary hospital readmissions, creating innovation centers. This bill starts to do that. There is something else this bill does but which some on the other side get all exercised over and which I think they get exercised over improperly; that is, ways to start to compare one drug versus another, compare one procedure versus another, one medical device versus another. We have to start doing more of that with a nongovernment agency, with a private-public agency that works together so it gives good, solid information so we have more evidence-based medicine in America. Right now, a lot of docs want to do the right thing, but what they do depends on the drug rep who comes in their office and starts peddling a certain drug. Docs feel uneasy about that, they do not like it, but they are so busy they see so many patients, it is hard to keep up to date. So we are trying to help them keep up to date with evidence-based medicine, and with a lot more health IT, health information technology, so they can get access to the best evidence through these various organizations. There are just so many reasons this legislation is so important. I personally believe we have to move a bit toward what is called integrated systems. We hear about Geisinger, the Mayo Clinic, the Cleveland Clinic, Intermountain Healthcare. There is some home health out in Seattle where doctors and hospitals and nursing homes and pharmacists are more integrated, and that, therefore, cuts down on cost, increases quality. It is more patient centered. It is more care coordinated. This legislation helps us move in that direction. We are just trying to get started with this legislation, get started in doing some of the right things we know we should do. We do not have all the answers. Nobody has all the answers. But if we get this legislation passed, in the next couple, 3 or 4 or 5 years, working with the basic underpinnings of this legislation, we are going to help correct some mistakes. We are going to see some new opportunities. We are going to be working on getting health care costs down, which we have to begin doing to help our people, help our companies. We are going to work to get more coverage so more people have health insurance. It is an embarrassment today. It is an absolute embarrassment that the United States of America, an industrialized country, does not provide health insurance for its people. It is more than an embarrassment. It is a travesty. It is a tragedy. It is just wrong, it is morally wrong. So this legislation gets us moving on the right track. It helps Medicare beneficiaries not hurt them, as the other side would like you to believe. It does not unnecessarily harm doctors and hospitals. They kind of go along with this. They kind of know it is the right thing to do. They are still getting big increases in payments, and there are other reforms here which I have not the time to mention tonight. But I strongly urge us to say: Hey, this is the right thing to do. Let's get started. Let's pass this legislation and certainly trounce this committal motion to stop what we are doing. It is not right to stop this. We are getting started. Let's keep going. I yield the floor.

Mr. BAUCUS. Mr. President, I didn't think there was a time agreement here.

Mr. BAUCUS. Mr. President, I understand we have several Senators who wish to speak. First, the Senator from Michigan, Ms. Stabenow, then Senator Hatch; Senator Cardin would be third. I don't want to tread on any toes. I say to Senator Cardin, there is a little bit of time constraint. We are alternating. We are respecting the alternating back and forth. The Senator from Michigan is next, Ms. Stabenow.

Mr. BAUCUS. Mr. President, as I understand it, there are a couple Senators left, besides myself, Senator Sessions and Senator Burr. There may be others, but I see them at the moment. America's health care system is in a crisis. It is a crisis not just for the 46 million Americans who lack health insurance; it is also a crisis for those who have health insurance but are worried they cannot afford to keep it. It is also a crisis for those who are underinsured and those who have poor health insurance. Rising health care costs affect families and American businesses. That we know. Health insurance premiums continue to outpace wages and inflation by a large margin. Between 1999 and 2008, premiums for employer-sponsored health benefits more than doubled. In that 9-year period, they increased 117 percent for families and individuals, and they increased 119 percent for employers. In each case, both for families and for employers, health insurance premiums doubled. Clearly, that is outpacing wages. I think the margin is 5 or 6 to 1, with premiums going up compared with wages for Americans. Health care coverage for the average family now costs more than $13,000 a year. If the current trend continues, by 2019, the average family plan will cost more than $30,000. That is over a 10-year period--from $13,000 for the average family today to $30,000 that family will pay then. Annual health spending growth is expected to continue to outpace average annual growth in the overall economy by 2 percent over the next 10 years. Health care spending is going up faster than the economy is growing. Add to that the insult, frankly, that this year alone not only would health spending increase 5 percent but GDP is expected to decrease two-tenths of a percent. So the gap is widening even further. Americans spend $4.5 million in health care every minute of every day. Think of that. We, in America, spend about $4.5 million in health care every minute. That is $2.5 trillion a year. It is pretty hard for anybody to get his or hands around 1 trillion, but we are talking about $2.5 trillion that Americans spend on health care every year. Without reform, health care expenditures will increase to $4.4 trillion in just the next 9 years. That would be more than one-fifth of our economy. So health care is taking a bigger and bigger bite out of our economy. These are not just numbers. Every 30 seconds, another American files for bankruptcy after a serious health problem. Think of that. Every year, about 1.5 million families lose their homes to foreclosure. Why? Because of unaffordable medical costs. In America, nobody should go bankrupt because they are sick. That is immoral. These numbers tell us what we have to do. We have to do two things at once. First, our health care reform bill must provide health care for millions of Americans who today don't have health insurance. At the same time, we must reduce the rate of growth in health care spending. We must do both. To be successful, health care reform must rein in the cost of health care spending, and we must succeed. Millions of Americans depend on it. Our plan is to reduce the Federal budget deficit by $130 billion over the next 10 years. Think of that. Many have said an economic recovery is through health care reform. We have to get control of our deficits. One way to do that is to get control of our health care spending. The bill before us now reduces the deficit by $130 billion over the next 10 years. We need to go much further, clearly, but that reduction is sure a lot better than no reduction. At the same time, our plan would reduce the number of uninsured by 31 million. It would reduce the number of Americans who are uninsured and, at the same time, we will cut the Federal budget deficit. So we are doing both. This bill reins in costs through changes in spending, reforms how providers deliver health care, and it changes the tax treatment of health care. Savings from this bill are estimated to total $106 billion in 2019. The CBO, Congressional Budget Office, which we all rely upon, expects that, in combination, it would increase 10 to 15 percent in the next decade; that is, savings growth, creative savings would grow by that much. That is what CBO says. That is a strong rate of savings. Those are all provisions to control the excessive growth in health care spending. Our plan also reevaluates the tax treatment of health care. The current Tax Code includes numerous health care subsidies and incentives. The current tax treatment of certain health care expenses encourages people to spend more on health care than they need to. Why? Because there is no limit under the law, none; that is, all employer- provided health care benefits in America today are totally tax free. The more the benefits are, if a company wanted to provide not only a Cadillac policy but diamond and gold benefits--great benefits--it is not needed tax free. That tends to encourage excessive health care spending. These indirect health care costs totalled nearly $200 billion in 2008. That makes health care the largest Federal tax expenditure. Health care today is the largest Federal tax expenditure. Our laws changed about 60 years ago and moved in that direction, limiting subsidies for expensive insurance plans. Our bill limits incentives to overspend on health care. Our bill will help to slow the growth of health care spending. Also, the CBO, in a letter they sent to the Congress yesterday, concluded there is about--this provision, the tax on so-called Cadillac plans, would result in a reduction in premiums those persons would otherwise pay--a reduction of, I think, about 5 to 7 percent. There has been a lot of concern in this body and beyond this body that that provision--the Cadillac plan provision--would raise costs for those folks who have those plans. The CBO concluded that the premiums for those kinds of plans would be reduced, I think, by 5 to 7 percent, rather than compared with current law. Several parts of our plan have the effect of reducing costs. I mentioned excess tax on high-cost insurance premiums, and that is a powerful one. Our plan also caps flexible health savings accounts. It puts a cap on them so it is not unlimited. There is no cap, so the Tax Code tends to encourage excessive use of that provision. Our plan would also conform with the definition of qualified medical expenses, the definition used by the itemized deduction for medical expenses. That, too, will help. Reducing existing tax expenditures for health care costs is one of the best ways to slow the growth of health care spending. We could use our code, all the tools available. Our goal is not only to reduce costs but also improve quality. There are many provisions in the bill that accomplish that result, which would improve the quality of health care. A lot of people hear us talk about how costly health care in America is today. It is costly--too costly. There is a lot of waste. We are enacting provisions to cut out the waste. I sense some Americans are thinking: Gee, maybe they are going to cut my Medicare benefits and reduce the quality back there in Washington, where they are worried about excessive health care costs. The exact opposite is the case. All the provisions in here enhance the quality of health care. The list is very long. One that immediately comes to mind is additional spending for primary care doctors. We all know they are underpaid in America. They are not taking Medicare patients, and they are going out of practice, especially in rural areas. This legislation adds 10 percent additional payment to primary care doctors in each of the next 5 years. That will help primary care doctors continue to practice. I might mention that health information technology will also help improve quality. There are lots of demonstration projects and pilot projects to improve quality through bundling, care organizations, reining in excessive readmission rates some hospitals have. We also have an outfit that compares how drugs work compared with other procedures. All that is going to help address quality. I want folks to know that while we are reducing costs--that is true because costs have to be reduced--we are also increasing the quality of health care in America. There are many other incentives in this bill that I don't have time to mention tonight that accomplish that result. In response to the excise tax on high-cost insurance, insurance companies will offer lower cost plans that fall under the thresholds. I think that is one of the reasons why premiums for those folks will fall. This will give consumers a lower cost alternative. These plans will still have the minimum level of benefits that will be required by law under the health care system. Other changes to the tax treatment of health expenses will also help individuals make more cost-effective health care decisions. For example, our plan would require employers to tell their employees the value of their health insurance. That reminds me two of the other provisions for increasing transparency so hospitals tell people what they charge for various procedures. I think the same should also apply to physicians so people have a better idea what they will pay or their insurance company will pay for these procedures. As I said, our plan will require employers to tell their employees the value of their health insurance. This will help people to know how much they are actually spending. I mentioned changes to flexible savings accounts, health savings accounts, and the definition of ``medical expenses.'' That will all help. It will also help to reduce costs by increasing competition. That has not been mentioned enough on the floor. This bill increases competition. We all know that in too many of our States, there are too few health insurance companies. In my State of Montana, Blue Cross/Blue Shield provides at least half the market. There is another company that is basically the rest. In some States, Blue Cross has the entire market. It is wrong. There is not enough competition. The exchange we are putting in place will encourage competition. Do you know what else will encourage competition? That is all the insurance market reforms--all of them--telling companies they cannot deny coverage based on a preexisting condition, telling companies they cannot rate according to health status, dealing with rules in the States, which means when you go to buy insurances--especially as an individual--there will be competition based on price. Companies will basically offer many of the same products, but they cannot deny coverage for preexisting conditions. The effect of that will be prices should come down because there will be more competition when insurance companies base it on price. Then there is the public option. That is another addition. That is in this bill. We don't know if it will or not. There are a lot of ways we help provide competition. It will help more competition, and transparency will help more competition. Competition is going to help bring down the costs. Our bill will reduce costs also by reforming health care delivery system--I mentioned a lot of that already--including how we pay for doctors. The bill is balanced. It finds savings in health care outlays-- savings that are realistic, that make sense. It looks to reduce health tax expenditures. That is a fancy term for deductions. The bill reduces the Federal deficit in the first 10 years. That point needs to be driven home. This bill reduces the Federal deficit in the first 10 years and the subsequent 10 years will have a positive effect bringing down the budget deficit. In fact, CBO says the second 10 years of our plan will cut the deficit by a quarter of a percent of the gross domestic product. That is about $450 billion. That is nearly $\1/2\ trillion in deficit reduction. We need to remember the cost of doing nothing is unacceptable. Basically, we have two choices in life: try or do nothing. To ask the question is to answer it. Of course, we tried. Our Nation is in crisis. We have a health care crisis. It is a formidable task. It is exceedingly complex and difficult. But we have an obligation to try, at least try, to fix it. If we try, then that poses a second question. If we try, we ask the question: Do we try our best or not? The answer is obvious: We try our best. This legislation is a combination of a year or two of work by folks in the medical profession, of health care economists--Americans who are trying to find ways to get control of costs and improve quality. There are not a lot of new ideas here. They are ideas that have been percolating around for the last year or two. Some are in Massachusetts, some in other States. Some of it is going into integrated systems, such as Geisinger and Intermountain. The idea of bundling is already practiced by other institutions. There is not a lot that is terribly new. We are pulling together, we are helping establish a policy in our country that comes up with a plan, a system in America that allows doctors and patients to have total free choice. They choose. We are helping doctors with the best evidence, the best information so they can focus on the patient care even more than they are now. We are cutting down the budget deficits. That is very important. And we are also helping Medicare by extending the solvency of Medicare another 5 years. These are things we pulled together and have to do. I very much hope we can move on and get this legislation passed and work with the House and the President signs a bill that we can start finally putting together something of which we will be very proud. Our country does not have a health care system today. It is a free-for-all. It is a free-for-all for all kinds of groups. This is the first effort to get something together that works, giving doctors and hospitals and patients the choice they want to have and they should have. We are also bringing costs down and improving quality of health care.

Mr. BAUCUS. Mr. President, I believe Senator Durbin may be coming to the floor. In the meantime, I suggest the absence of a quorum.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, before I give a statement on the bill, I wish to compliment the Senator from Maryland for standing up for and essentially helping the health care of women. As she has pointed out, women are discriminated against today in America in various ways. Her amendment addresses some of that discrimination. I very much appreciate that. I know all women in the country do. I do, too. I have a mom. I have sisters. I have women in my family, and I very much care. I don't know if she made this point, but about 80 percent of health care decisions made for families are made by women. It is all the more important women are not discriminated against, partly because they make so many decisions that affect health care for Americans, but second, women themselves are often discriminated against. Some States have gender ratings which discriminate against women. In other States a preexisting condition is a factor that discriminates against women. I thank the Senator from Maryland. She has hit the nail on the head. It is another reason this health care reform is going to mean so much for so many Americans. I personally very much thank the Senator from Maryland. In the Presidential campaign of 1912, Theodore Roosevelt's platform said: We pledge ourselves to work unceasingly in State and Nation for . . . the protection of home life against the hazards of sickness . . . through the adoption of a system of social insurance adapted to American use. Today, nearly a century later, we are closer than ever to enacting meaningful health care reform. As in Teddy Roosevelt's time, we seek protection against the hazards of sickness. Of necessity we seek a system uniquely adapted to American use. And recognizing the daunting task still ahead of us, we pledge ourselves to work unceasingly to get the job done. In the years since Teddy Roosevelt, some of our Nation's greatest leaders signed up for this job. But at the same time, we have never faced a greater need to get the job done than we do today. Why is that? Basically because health care costs are skyrocketing out of control. Every day American businesses are forced to cut benefits for their workers. Why? To remain competitive in the global marketplace. Every 30 seconds another American files for medical bankruptcy. Just think of that. Every 30 seconds another American files for medical bankruptcy. Every year, about 1.5 million families lose their homes because of health care costs. Our system is in crisis. We have a historic need and we have a historic opportunity. We have an opportunity to enact groundbreaking reform that will finally rein in the growth of health care costs and help bring financial stability back to American families and businesses. Unfortunately, there are some who stand in the way. Unfortunately, there are some who are spreading misinformation about how health care reform will work. On this very floor I have heard arguments that health care reform is about the government trying to take over health care. That is false. The truth is, health care reform is about allowing patients and doctors to take back control of health care. We need to allow patients and their doctors together to take back control from the big insurance companies. Our plan would not increase the government's commitment to health care. But don't just take my word for it. The nonpartisan Congressional Budget Office says: [D]uring the decade following the 10-year budget window, the increases and decreases in the federal budgetary commitment to health care stemming from this legislation would roughly balance out, so that there would be no significant change in that commitment. That is right, health care reform will not increase the Federal Government's budgetary commitment to health care. I have also heard it argued that health care reform will increase the budget deficit. That, too, is false--plainly, patently false. The bipartisan Congressional Budget Office says our plan would reduce the Federal deficit by $130 billion within the first 10 years--reduce the deficit in the first 10 years. That trend would continue, the CBO says, over the next decade. During the next decade, CBO says our bill would reduce the deficit roughly $450 billion. That is nearly one-half trillion dollars in deficit reduction, according to the Congressional Budget Office, in the second 10 years. I have also heard it argued that health care reform will raise taxes. That, too, is false. In fact, health care reform will provide billions of dollars in tax relief to help American families and small businesses afford quality health insurance--tax cuts. The Joint Tax Committee--again bipartisan and which serves both the House and the Senate--tells us, for example, that our bill would provide $40 billion in the tax cuts in the year 2017 alone--$40 billion in tax cuts in the year 2017. The average affected taxpayer will get a tax cut of nearly $450. The average affected taxpayer with an income under $75,000 in 2017 will get a tax cut of more than $1,300. Let me repeat that. The average affected taxpayer with income under $75,000 in 2017 will get a tax cut of more than $1,300. They will also get a tax cut in earlier years, but it ramps up to that amount in 2017. In the same vein, I have heard claims that health care reform will result in an increase in higher costs for Americans. That, too, is false. Health care reform will not result in higher costs for Americans. Health care reform is fundamentally about lowering health care costs and making quality health care affordable for all Americans. Lowering costs is what health care reform is designed to do, lowering costs; and it will achieve this objective. How? In many ways. First, health care reform will end abusive practices by insurance companies. Reform will stop insurance companies from denying coverage or hiking up rates for those with a preexisting condition. We stop that in this legislation. That will lower costs. Reform will stop insurance companies from dropping coverage or reducing benefits for those who get sick. Those reforms protect consumers, and they will protect Americans and reduce premium costs for Americans who are sick. These reforms will also help lower costs for small businesses and their employees. Right now, if one employee in a small business gets sick--just one--insurance companies can double the premiums they charge the whole business. I know that is true. I have heard that time and time again from small business owners in Montana. That is just because one employee gets sick, the insurance companies jack up premiums, double the premiums they otherwise would charge the whole business. That is just wrong. We stop that in this legislation. How else do we lower costs in this bill? Health care reform will provide billions of dollars in tax credits and reform will limit out- of-pocket costs such as copayments that insurance companies are able to charge. We limit them. This will also help to ensure Americans can afford their total health care costs and not just their premiums. That is very important. Premiums and out-of-pocket costs are both addressed by this bill. It limits growth in premiums and also limits growth in out-of-pocket costs. So total cost--premiums plus out-of- pocket costs--for Americans will be lower under this legislation than otherwise would be. Third, health care reform will work to repeal the hidden tax of more than $1,000 in increased premiums that American families pay each year in order to cover the cost of caring for the uninsured. Today, millions of Americans without health insurance are too often forced to turn to emergency rooms to get the care they need, and then health care providers shift the cost of that care to other Americans with health insurance. People with insurance, therefore, pay higher premiums. By providing quality, affordable health insurance to millions more Americans, health care reform will reduce this hidden tax and reduce premiums for all Americans--$1,000 per year per family due to uncompensated care. That is that hidden tax. This bill will virtually stop that hidden tax, stop that additional $1,000 that goes to average family premiums. How else do we reduce health care costs? By providing affordable health care to more Americans which will increase the number of Americans in the insurance market. Why? What is so good about that? One reason is more people will have health insurance. But also it will spread the risk of paying for an accident or disease more broadly. Spreading the risk more broadly should lower premium rates for everybody. It is a basic tenet of insurance. Fifth, health care reform will reduce costs by cutting administrative redtape. That is no small item. Today, insurance companies spend a lot of time and money finding ways to discriminate against people. They spend time and money to find ways to drop coverage, and insurance companies pass those administrative costs on to all Americans in the form of higher premiums. The figure I heard is about 18 percent of American health care dollars is administrative costs. This legislation would dramatically reduce that percentage to a much lower number. We don't know to exactly what level yet but a much lower level. About 18 percent of total health care dollars go to pay administrative costs. That is not the case in other countries. They pay 4 to 5 percent in other countries. We have to get that down in America, and health care reform will significantly achieve that result. Health care reform will outlaw this discrimination, and also reform will eliminate those administrative costs that go along with it. Furthermore, health care costs will work to streamline administrative procedures across the board by requiring standard enrollment forms and marketing material through insurance exchanges. That, too, will help streamline procedures. That, too, will help reduce administrative costs for providing for standard enrollment forms and also standard marketing materials through insurance exchanges. That is going to lower administrative costs and make it much easier for a person to shop and know which policy is best for him or her. With the other reforms we are making competition is more on the basis of price not just underwriting, a fancy term for denying because of a preexisting condition and putting in all those extra escape clauses insurance companies often provide in small print. In a letter released today, the Congressional Budget Office said: Compared with plans that would be available in the nongroup market-- And they are referring there to the individual market-- under current law, nongroup policies under the proposal would have lower administrative costs. Let me say that again. Compared with plans that would be available in individual markets--individuals seeking insurance--under current law, individual policies under the proposal would have lower administrative costs. Lower, not higher. Lower. Six--another way to reduce costs. Health care reform creates insurance exchanges where consumers can easily shop and compare plans to find the right coverage. Exchanges will make it easier for Americans to choose the most efficient plans, and that will reduce their costs and put pressure on insurance companies to offer lower cost, higher quality plans. Seven--still another way this bill reduces costs. Small business insurance exchanges will allow small companies to pool together to spread their risk and increase their buying power. More pooling available for small business insurance exchanges--this will allow small businesses to negotiate lower rates and provide more quality insurance plans with lower premiums to their employees. Eight. Health care reform will strengthen oversight and enforcement measures to cut down on fraud, waste, and abuse in the health care system. Fraud, waste, and abuse are estimated to cost our health care system more than $60 billion every year. This bill will help reform our system to reduce fraud, waste, and abuse, which eats up way too many health care dollars. Nine. Health care reform will move the focus of our system toward efficiency and value with payment incentives that reward quality care-- not quantity and volume but reward quality care, reward outcomes. Over the long run, paying doctors and other health care providers for quality instead of quantity will reduce health care costs. Ten. Health care reform will lower costs by working to change the focus of our health care system from treating sickness to promoting wellness. The big problem we have today is that we treat sickness. We don't spend enough time promoting wellness. Reform will make critical investments in policies that promote healthy living and help prevent costly chronic conditions that drive up costs throughout the system. These are just 10 examples of how health care reform will reduce health care costs and lower premiums for American consumers. There are many more, but these are those 10, as I said. On the other hand, without reform; that is, without passing this legislation, costs are guaranteed to continue to skyrocket out of control. Since Congress failed to enact health care reform in the 1990s, health care premiums have risen eight times faster than wages. Consider that. Since the last time we attempted to pass health care reform--and failed--in the 1990s, health care premiums have risen eight times faster than wages. And if we don't reform our health care system now, premiums will increase 84 percent in the next 7 years. And that is just premiums. What about out-of-pocket costs? Those, too, will increase at a rate much faster than wage increases. Today, health care coverage costs the average American family more than $13,000 a year, according to the Kaiser Family Foundation. If current trends continue without reform, the average family plan will cost more than $30,000 a year in the next 10 years. That is up from $13,000 today to $30,000 10 years from now. And businesses could see their health care costs double in that same time. Without reform, our Nation's long-term fiscal picture is almost certainly unsustainable. As Peter Orszag said when he was Director of the Congressional Budget Office: Rising health care costs represent the single most important factor influencing the Federal Government's long- term fiscal balance. He was right. Without reform, instead of working to reduce our national deficit and stabilize the Federal budget, we will see total health care spending nearly double to encompass one-fifth of our gross domestic product in less than 10 years. And the Congressional Budget Office projects entitlement spending will double by the year 2050. Without reform, millions of uninsured Americans will continue to suffer. A Harvard study found that every year in America, lack of health care coverage leads to about 45,000 deaths. People without health insurance have a 40-percent higher risk of death than those with private health insurance. You have a 40-percent higher chance of death if you don't have health insurance compared with those who do. That is 46 million Americans at risk today because they do not have health insurance. A recent Johns Hopkins study found that children without insurance have a 60-percent higher risk of death than those with private health insurance--a 60-percent higher risk of death than those with private health insurance. Another recent Harvard study found that the risk of dying from car accidents and other traumatic injuries is 80 percent higher for those without insurance--80 percent higher. The risk of dying from car accidents and other traumatic injuries is 80 percent higher if you don't have health insurance. In the greatest country on Earth, no American should die simply because they do not have health insurance. So, Mr. President, we are at a crossroads in history. We have a historic opportunity to enact meaningful health care reform that will work to stabilize our economy and provide quality, affordable health care coverage for millions of Americans. We are not the first to be here, but we have come further than ever before. We laid the groundwork in the Finance Committee and the HELP Committee. We held many hearings and countless hours of meetings on health care reform. Each committee crafted meaningful legislation and held exhaustive markups where we incorporated amendments from both sides of the aisle. We produced balanced, meaningful legislation, and I am proud--I am very proud--of the work both committees accomplished. Now we have one health care plan before us in the Senate, two basic bills merged together. We have an opportunity to debate that plan and offer amendments to make it even better. Then we will be called upon to vote. The health care of our Nation is depending on us. The health care of our economy is depending on us. History itself is depending on us to answer the call. I am confident we will. I am confident we will at long last answer the call of history. I am confident we will soon enact meaningful health care reform that will lower costs and bring quality, affordable coverage to millions of Americans.

Mr. BAUCUS. Madam President, I have a few small matters here before I yield to my friend from Iowa. First, I cannot thank my colleague from Connecticut enough. He has worked so hard as the former chairman of the HELP Committee and now as a very active participant in the HELP Committee, along with Chairman Harkin. I cannot thank him enough. The Senator from Connecticut has worked on health care in such a constructive way. I deeply appreciate his efforts. Before I give up the floor, I wish to pay my strongest compliments to my colleague from Iowa, Senator Grassley. Senator Grassley is one heck of a guy. He represents his State, in my judgment, very, very well. As I am sure the Presiding Officer knows--certainly my colleague from Connecticut knows--we have worked very closely together, Senator Grassley and I, on a nonpartisan basis as much as we possibly can because we both think--and I know most people think--good legislation is legislation where you work together, not where you are fighting each other. Senator Grassley and I started out trying to get this bill put together on a bipartisan basis working together. As it turned out, we did not quite get there. But I know in the end he would very much like to find a way to vote for health care reform, as most Members of the Senate would. I am an optimist. I think most of us in this body are optimists. I have not given up yet. Who knows how this is going to evolve? Who knows what the amendments are going to be? Who knows what the votes are going to be in the next several weeks or so? But I am looking for an opportunity where Senator Grassley and other very constructive Senators will join us, all together, in a way, with a little give and take here, perhaps, to find a solution. So I just want to end by saying how much I appreciate the Senator. He does a super job.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, I ask unanimous consent that Stic Harris, a fellow in the office of Senator Franken, be granted floor privileges for the duration of the debate on H.R. 3590.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, a noted psychologist once said: To be mature means to face, and not evade, [a] crisis. . . . Our health care system is in a crisis. This crisis has been decades in the making, and history has made clear that this crisis will not solve itself. It is time for us to face the crisis. It is time for Congress to show mature leadership. It is time for us to reform health care, once and for all. For years now, we have prepared for this moment. The Finance Committee and the HELP Committee studied the issues thoroughly. We have held nearly 70 hearings, roundtables, and walk-throughs. We have studied this issue very thoroughly and exhaustively. We each produced a blueprint for reform--each committee--and we worked together with Leader Reid and President Obama to combine those blueprints into one solid plan. This week, tonight, we have brought that plan to the Senate floor. Tonight, we seek to begin that momentous debate. Tonight, we seek, at last, to face the crisis. We have a bill that will put Americans, patients, and their doctors back in control. We have a bill that will end harmful insurance industry practices. Under our bill, no longer will insurance companies be allowed to deny you health insurance. No longer will insurance companies be allowed to hike up rates for Americans with preexisting conditions, such as heart disease, cancer, or diabetes. No longer will health insurance companies be able to take away your health insurance or reduce benefits when people get sick. Under our bill, no longer will insurance companies be able to limit the amount of health care you can use in a lifetime. No longer will insurance companies be able to put unreasonable limits on the amount of health care you can use in 1 year. If you pay your bill, the insurance company must renew your coverage and provide your benefits. No longer will insurance companies be able to discriminate based on gender or health status. No longer will insurance companies be able to charge more for women or for people who are sick. Our bill will also require insurance companies to disclose the share of premiums that goes to medical benefits. That is new and very important. No longer will insurance companies receive tax credits when they use their profits to provide excessive executive paychecks. Our bill is fully paid for. It is fiscally responsible. It will lower health care costs, and it will reduce the Federal budget deficit. According to the Congressional Budget Office, our bill will reduce the deficit by $130 billion in the first 10 years. Over the next decade, it will further reduce the deficit by about one-quarter of 1 percent of gross domestic product. That is hundreds of billions of dollars in deficit reduction. As well, our bill will provide billions in tax cuts for American families and small businesses. Our bill will create new marketplaces called insurance exchanges. Individuals and small businesses will be able, quickly and easily, to view, compare, and buy health insurance plans. Today, many Americans already receive quality health care coverage through their employers. Many are happy with their current insurance plans. This bill will not change that. We keep the best of our current health care system. People who are satisfied with their current health insurance coverage will be able to keep it. But too many others do not have access to insurance, to quality insurance. For too many, this system is broken. Under our bill, new exchanges will provide one-stop shops where plans are presented in a simple, consistent format. Americans will be able to know exactly what they are buying. Insurance companies will have to compete on price and on quality, not on their ability to select the healthiest people or hide restrictions. Americans will be able to count on the health care coverage they buy. And tax credits will help to ensure all Americans can afford quality health insurance. Small businesses will also have access to exchanges and tax credits. Through small business exchanges, these companies will be able to pool together to spread their risk, increase their leverage, and enhance their choice, just as big companies do. Members of Congress will be required to buy their health insurance through the same exchanges that people in their own States use--exactly the same. No longer will there be a separate congressional health plan. Our bill will strengthen Medicare. It will improve benefits for seniors. And it will help to ensure Medicare is sustainable for future generations. Our bill will cut costs, but it will not cut benefits. Our bill will increase Medicare benefits. Our bill will provide seniors with free preventive care and wellness checkups. It will improve care for seniors with chronic conditions. And it will provide a 50-percent discount on brand-name prescription drugs to help close the doughnut hole, the gap in benefits in the Medicare prescription drug program. Our plan is a good, commonsense answer to the crisis facing American families and businesses. On this floor, here in the Senate, tonight, we have a historic opportunity to consider this plan. We have the chance to make it even better. We hope to have a full debate. But more important than the process or rhetoric, we have the opportunity, at last, to face the crisis. We have the opportunity to show mature leadership. At long last, we have the opportunity, the historic opportunity, to reform health care, once and for all. History is knocking on the door. Let's open it. Let's begin the debate to improve this bill before us today and provide the service all Americans expect us to perform when they elect us to this office. I yield the floor.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, I ask unanimous consent that Jacqueline Lampert, a Democratic Policy Committee staffer, be granted floor privileges for the consideration of H.R. 3590.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, due to an unfortunate illness in my family, I regrettably missed rollcall No. 352. If I had been present, I would have voted ``aye'' on the passage of S. 1963, the Caregivers and Veterans Omnibus Health Service Act of 2009. This legislation is very important to veterans living in Montana. Many of Montana's veterans live in rural areas, hours away from the closest VA facility, and this bill will improve access to health care in those rural areas. I am pleased to see this bill passed with bipartisan support. We must uphold our promise to honor our veterans and provide them with the benefits they have proudly fought for and deserve.

Mr. BAUCUS

Mr. BAUCUS. Today, I am pleased to introduce the Small Business Penalty Relief Act of 2009 with my good friend and Ranking Member of the Finance Committee, Chuck Grassley. The bill provides much needed penalty relief to small businesses across America that are being assessed large penalties by the Internal Revenue Service because they unknowingly invested in something called a ``listed tax shelter transaction.'' Many of these businesses thought they were putting their money into sound investments for the benefit of their employees and learned only after they were audited by the IRS that they instead had invested in something the IRS considers to be a tax shelter. Most small businesses do not have the resources to pay sophisticated tax lawyers and accountants to review all their business decisions. They have to do the best they can on their own. And that is how they ended up in the middle of a nightmare with the IRS. When a business invests in a listed tax shelter, the law requires that business to attach a form to the tax return telling the IRS about the shelter. If the business doesn't attach the form, it can be subject to a penalty of $200,000 per year. If the business has elected Subchapter S status, an additional $100,000 penalty applies at the individual level. Total penalties can add up to $300,000 each year. Multiply that by several years, and you can easily approach $1 million or more in penalties for a tax shelter you didn't even know you had. In the case of many small businesses, the annual tax benefit from their investment is quite minor--perhaps as small as $15,000. The $300,000 penalty plainly is out of whack. Just to be clear, Senator Grassley and I are not soft on tax shelters. We spearheaded legislation in 2004 that gave the IRS better tools to stop individuals and big companies from cleverly manipulating the tax code to avoid paying the taxes they owed. Our efforts were focused on egregious deals that cheated the U.S. Government out of millions and billions of dollars. Our efforts have made a serious dent in the proliferation of abusive tax scams and schemes. But we didn't intend that the 2004 legislation would end up threatening the existence of small businesses in Montana and across America, and the livelihoods of their employees who risk losing their jobs if the business goes under. Small businesses are struggling already. They don't need the added and unfair burden of a penalty that can be as much as 20 times larger than the taxes they saved. This bill changes the way the penalty is calculated. The penalty is based on a percentage of the tax benefit resulting from the investment. It is fairer and won't drive these companies out of business. Small businesses are the backbone of our Nation. Particularly in these tough economic times, we must make sure the tax laws reflect the important role that small business plays in our Nation's economic health and our citizens' economic security.

Mr. BAUCUS

Mr. BAUCUS. Today, I am pleased to introduce the Small Business Penalty Relief Act of 2009 with my good friend and Ranking Member of the Finance Committee, Chuck Grassley. The bill provides much needed penalty relief to small businesses across America that are being assessed large penalties by the Internal Revenue Service because they unknowingly invested in something called a ``listed tax shelter transaction.'' Many of these businesses thought they were putting their money into sound investments for the benefit of their employees and learned only after they were audited by the IRS that they instead had invested in something the IRS considers to be a tax shelter. Most small businesses do not have the resources to pay sophisticated tax lawyers and accountants to review all their business decisions. They have to do the best they can on their own. And that is how they ended up in the middle of a nightmare with the IRS. When a business invests in a listed tax shelter, the law requires that business to attach a form to the tax return telling the IRS about the shelter. If the business doesn't attach the form, it can be subject to a penalty of $200,000 per year. If the business has elected Subchapter S status, an additional $100,000 penalty applies at the individual level. Total penalties can add up to $300,000 each year. Multiply that by several years, and you can easily approach $1 million or more in penalties for a tax shelter you didn't even know you had. In the case of many small businesses, the annual tax benefit from their investment is quite minor--perhaps as small as $15,000. The $300,000 penalty plainly is out of whack. Just to be clear, Senator Grassley and I are not soft on tax shelters. We spearheaded legislation in 2004 that gave the IRS better tools to stop individuals and big companies from cleverly manipulating the tax code to avoid paying the taxes they owed. Our efforts were focused on egregious deals that cheated the U.S. Government out of millions and billions of dollars. Our efforts have made a serious dent in the proliferation of abusive tax scams and schemes. But we didn't intend that the 2004 legislation would end up threatening the existence of small businesses in Montana and across America, and the livelihoods of their employees who risk losing their jobs if the business goes under. Small businesses are struggling already. They don't need the added and unfair burden of a penalty that can be as much as 20 times larger than the taxes they saved. This bill changes the way the penalty is calculated. The penalty is based on a percentage of the tax benefit resulting from the investment. It is fairer and won't drive these companies out of business. Small businesses are the backbone of our Nation. Particularly in these tough economic times, we must make sure the tax laws reflect the important role that small business plays in our Nation's economic health and our citizens' economic security.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, I rise today to honor and pay tribute to Montana's fallen heroes, the dedicated men and women from our great State who have made the ultimate sacrifice in Iraq and Afghanistan since 9/11. Montanans proudly volunteer for military service at rates higher than any State in the country, higher per capita. Unfortunately, this distinction comes at a great price. To date, 40 Montanans have died and nearly 250 have been wounded in combat in Iraq and Afghanistan. Montana has now suffered more casualties per capita than any other State in the Union. This is staggering. It illuminates just how much our State's citizens have sacrificed in the service of our country. The famous World War II radio reporter Elmer Davis once said: This Nation will remain the land of the free only so long as it is the home of the brave. It is painfully apparent that Montana is home to some of the bravest men and women of all. Who are these fallen heroes? They range in age from 18 to 40. They hailed from places far afield, such as Troy and Glendive, Billings and Missoula, Lame Deer and Colstrip. They grew up in cities and towns, on ranches and farms, and on the reservation. Some heroes were Active-Duty warriors, others part-time citizen soldiers. They held ranks from lance corporal to lieutenant colonel. It amazes me that with such a variety of backgrounds, our heroes all shared the common bond of a desire to serve their country in this time of crisis and need. The Gospel of John, chapter 15, reads: Greater love hath no man than this: that a man lay down his life for his friends. No tribute could possibly express the extent of my gratitude for what these soldiers, sailors, airmen, and marines have done for their country. During Vietnam, the late Senator Mike Mansfield carried a casualty card in his breast pocket. In that same spirit, I, too, wish to honor their sacrifice by reading Montana's fallen heroes into the Record. The following Montanans were killed while serving in Operation Iraqi Freedom: Army SGT Travis M. Arndt, 23, Bozeman; Army SSG Travis Atkins, 31, Bozeman; my nephew, Marine Cpl Phillip E. Baucus, 28, Wolf Creek; Army SSG Shane Becker, 35, Helena; Marine PFC Andrew D. Bedard, 19, Missoula; Marine LCpl Nicholas William Bloem, age 20, Belgrade; Army PFC Kyle Bohrnsen, 22, Philipsburg; Army LTC Garnet Derby, 44, Missoula; Army SGT Scott Dykman, 27, Helena; Army SPC Michael Frank, 36, Great Falls; Marine LCpl Kane Michael Funk, age 20, Kalispell; Army SSG Yance T. Gray, 26, from Ismay; Army SSG Aaron Holleyman, 26, Glasgow; Army PVT Timothy J. Hutton, 21, Dillon; Navy PO2 Charles Komppa, 35, Belgrade; Army CPL Troy Linden, age 22, Billings; Army CPT Michael McKinnon, 30, Helena; Army SGT James A. McHale, 31, Fairfield; Army MSG Robbie McNary, 42, Lewistown; Marine LCpl Jeremy Scott Sandvick Monroe, 20, Chinook; Army PFC Shawn Murphy, 24, Butte; Marine LCpl Nick J. Palmer, 19, Great Falls; Army CPT Andrew R. Pearson, 32, Billings; Marine Cpl Dean Pratt, 22, Stevensville; Army SPC James Daniel Riekena, 22, Missoula; Army 1LT Edward M. Saltz, 27, Bigfork; Army PVT Daren Smith, 19, Helena; Marine Cpl Raleigh C. Smith, 21, Troy; Marine Cpl Stewart S. Trejo, 25, Whitefish; Army PFC Owen D. Witt, 20, Sand Springs; Army SPC Donald M. Young, 19, Helena; Army PVT Matthew T. Zeimer, 18, Glendive. The following Montanans were killed while serving in Operation Enduring Freedom: Navy aviation electronics technician, Andrew S. Charpentier, 21, Great Falls; Army 1LT Joshua Hyland, 31, Missoula; Marine Sgt Trevor Johnson, 23, Colstrip; Army SGT Terry Lynch, 22, Shepherd; Army PFC Kristofer T. Stonesifer, 28, Missoula. The following Montanans died shortly after returning home from Operation Iraqi Freedom: Army CPL Christopher M. Dana, 23, Helena; and Army SGT George Kellum, 23, Lame Deer. It pains me dearly to read this list out loud and I cannot begin to imagine how many broken hearts each name represents back home. Our fallen heroes fought and died for our great Nation and all it represents. We owe them a debt of gratitude that can never be fully repaid. We must honor their legacies by remembering their sacrifice as we carry on with our lives. To all of Montana's families staring at an empty bedroom or an empty chair at the dining room table: You will always be in my thoughts and prayers. I pledge to do all I can to honor your fallen loved ones. To Montana's fallen warriors: We will never forget. I yield the floor. I suggest the absence of a quorum.

Mr. BAUCUS

Mr. BAUCUS. Madam President, I rise today to speak about legislation that I introduced on Friday with Senator Bingaman--the Land and Water Conservation Authorization and Funding Act of 2009--which would establish permanent funding for the Land and Water Conservation Fund. This bill makes it certain that the funds available in the Land and Water Conservation Fund--LWCF--are not subject to the annual whims of Congress, but instead that these funds are available at a steady, reliable, certain level that will allow us to protect land and water well into our future. For over 30 years, the LWCF has been used to purchase lands from willing sellers for the purposes of conservation. It is authorized at a spending level $900 million per year. However, Congress has rarely approved the full $900 million, and appropriations have varied widely. The result is a program that sometimes moves forward in fits and starts rather than with a consistent level of investment from year to year. Even with this situation, the LWCF is an incredibly successful and important program for our land conservation needs. In Montana, the LWCF has funded the acquisition of key treasures such as the Sun Ranch in Madison County and the Iron Mask Ranch in Broadwater County. We have areas all over Montana in the pristine ecosystem of the Rocky Mountain Front that are standing in line, just waiting for LWCF funds to be available. We cannot afford to wait any longer. We need to take steps today, this Congress, to fix this long-standing problem and establish permanent funding for the LWCF to protect Montana's resources well into the future.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, the provision of S.A. 2712 to H.R. 3548, The Worker, Homeownership, and Business Act of 2009 as voted on yesterday, November 4, 2009, provide relief for unemployed workers, homeowners and businesses. Senate Finance Committee Chairman Baucus has asked the nonpartisan Joint Committee on Taxation to make available to the public a technical explanation of the bill, JCX-44-09. The technical explanation expresses the committee's understanding and legislative intent behind this important legislation. It is available on the Joint Committee's Web site at www.house.gov/jct. Mr. President, I ask unanimous consent to have the technical explanation printed in the Record.

Mr. BAUCUS

Mr. BAUCUS. The Senator from Florida is correct. The purpose of the legislation is to eliminate fraud by requiring documentation of the proof of purchase. It is the Senate's intent that the IRS should accept retail sales contracts from taxpayers as proof of purchase of a manufactured home in the event that a settlement statement is not available.

Mr. BAUCUS

Mr. BAUCUS. I thank the Senator from Connecticut, Mr. Lieberman, for bringing this matter to my attention. We certainly want to avoid a policy that inadvertently discourages Americans from returning to work.