Thomas Coburn

Mr. COBURN

Mr. COBURN. Mr. President, I ask unanimous consent to waive the 60- vote threshold on this vote and have a voice vote.

Mr. COBURN

Mr. COBURN. It is interesting. We have a nongermane amendment that is outside the bounds of the Constitution, doing something that is not the role of the Federal Government, that we are going to expand the cost at a time when we are bankrupt, and five germane amendments that actually lower the cost of the airport improvement fund, actually help NextGen in terms of money, help preserve the airport trust fund, and we are not going to be allowed to bring them up? If that is the way we are going to operate, then you can count on me, knowing procedure around here, that we will have a very difficult time moving ever to a Leahy amendment. Mr. President, I came to the floor to discuss what we are trying to do and to be helpful in moving that along. I have now heard that I will not be allowed to offer these amendments or at least bring them up. I am going to discuss each one of them, and I will object to any unanimous consent moving forward on any area until we have an opportunity, as is the Senate tradition, to have a debate and bring up amendments. If we are not allowed to do that, then I am sure we are going to start going backward again. Passing an FAA authorization bill, as the chairman and ranking member have tried to do, is a significant priority for Congress. We have a system of air traffic control that needs to be modernized. We have monies that we are putting forward to do that. We have not had the oversight, according to the inspector general, that is necessary for those programs. In this bill, we have authorizations for moneys that are not priorities for this country at a time that we are facing a $1.6 trillion deficit, we have an unemployment rate in excess of 9 percent, and interest rates that are going to rise in the future. My amendments, which I am happy to have voted on and voted down, lead us to a path that secures and enhances the airport improvement fund and the trust fund, makes common sense that 99 percent of the American people would agree with, excludes Alaska because it is a totally different animal when it comes to the Essential Air Service requirements, and will, in fact, enhance the trust fund. So I am very sorry the chairman refuses to allow my amendments to come up, but I will offer them and have him object in total. What has to happen with every program in this country is that wasteful spending, low-priority spending, and duplicative spending has to be eliminated. Although I think the chairman and ranking member did a fairly good job on this bill, there are areas where we can eliminate wasteful spending, there are areas where we can eliminate duplicative spending, and there are areas where we can say: This can't be a priority now given the financial fix in which we find ourselves. During our current budget deficit, the revenues coming into the airport trust fund are lower than expected, and we have this very real need on NextGen development. Congress has to limit somewhere and make a priority next year, and I think they have tried to go in that direction, and these amendments will do such a thing. The first amendment I would like to talk about is the airport improvement Federal cost share reduction amendment. Across this country, we now have money being spent on low-priority projects in airports that have very little traffic or minimal traffic, and we are not spending money on the airports for safety and for the airports in which we have the vast majority of traffic. We have seen one program in particular where billions of dollars for low-priority projects have been spent. I would just tell you, if we are ever going to get out of the jam we are in, some common sense has to be applied in that we cannot do everything everybody wants, and there is going to have to be some sacrifice in these areas. The whole goal of this first amendment is to discourage low-priority, wasteful aviation projects that would not be funded by increasing the non-Federal cost share to just 25 percent over 3 years. In other words, it is 5 percent now, and so it is 95 percent of the government's money, and all we do is, over 3 years, move it to where you have to pay 25 percent. It is going to discourage a lot of low-priority projects because the communities or the States have to have a greater participation. There is no program in the Federal Government that has a grant process and a funding process where the Federal Government pays 95 percent other than this program--not one. So we are encouraging money to be wasted on low-priority projects by maintaining 95 percent Federal funding. This gives us 3 years to adjust to 75 percent, which probably should be 50 percent but 75 percent given our fiscal issues. Nonprimary airports could initially have up to 90 percent of their airport improvement projects covered by the Federal Government. In recent years, we raised that, under Public Law 108-176, to 95 percent. This is 20 percent higher than the same cost share for other airports qualifying for this $4 billion program. It is $4 billion a year. Lest you think I am too critical, let me give you some examples. Two flights a day--two flights a day, noncommercial flights, just two private flights a day--is the average for Kentucky's Williamsburg- Whitley County Airport. We spent $11 million there to build an airport with a 5,500-foot lighted runway, a colonial-style terminal, and hundreds of acres for growth even though it does not have one airline passenger and averages two flights a day. Now, tell me, if you ask the average American: Should we spend $11 million there or should we make sure we can take care of the kids who do not have what they need in this country, should we spend $11 million there or not borrow another $11 million from the Chinese, should we spend $11 million there or should we, in fact, make sure the airport trust fund has the money to do high-priority projects, such as large airports or NextGen, which one would the average American think we should do? Lest you think I am picking on Kentucky, Halliburton Field in Duncan, OK, got $700,000 for a pilot room and a reception room. We are building for private aviation with taxpayer money--a low priority. We are building a nice pilot room and a reception room for the private pilots who fly there. Now, tell me how that is a priority in our country today. That is my own State. We are sending money down a hole because we refuse to make tough choices. All this amendment does is say: Let's move it from 95 percent, over 3 years, to 75 percent so we do not get the lower priority projects funded, because we are too generous with what the Federal Government contributes. The chairman may not like it, but I will bet you the average American thinks it is a pretty smart thing to do given the state we are in. All bets are off on the politics of this. I have never been accustomed to playing the politics of it at all, but there are just as many people on the left who think we ought to cut spending as there are on the right. America gets it. The only place that does not get it is here. And this does not do anything except enhance what can be done for higher priority issues within our aviation community. That is all it does. It is a small, simple step. And by rejecting or not allowing an amendment such as this to come forward, what we are saying is that we are going to keep kicking the can down the road; we are not going to pay attention to the American public. We are going to hide from the reality that is coming very soon for this country. We will not have any money to put into airport improvement programs. We will not have the money to fund a NextGen program. It will become a low-priority program unless we wake up and start doing what the rest of America recognizes we have to do; that is, start living within our means. The next amendment is an amendment that is a bipartisan amendment between the Senator from Alaska and myself. It is an earmark rescission amendment. All it says is the earmarks that have been out there, that the money hasn't been spent for over 9 years, giving 1 year for the agencies to decide whether they think that is so, should be rescinded. It puts $500 million, a half a billion dollars at a minimum, back in the public Treasury. Why would we not want to do that? We have $2.6 million sitting in Atlanta that can't be spent on anything except the 1996 Olympics. Why wouldn't we take back that $2.6 million? It was earmarked. It didn't get spent. But it is sitting out there in a hole. We can reverse that. Estimates are we will save a billion dollars. The conservative estimate at a minimum is $500 million. Yet we are not going to allow this amendment to be considered? It makes no sense. The next amendment calls on us to sacrifice a little bit. The Essential Air Service Program has multiple subsidies where people can easily drive 1 hour and 20 minutes and get to a regional airport that doesn't require any subsidies. All this amendment does is move it to 100 miles from where it is today, which is 70. It moves it to 100 miles and says if you are less than 100 miles, you ought not be eligible, sometimes to the tune of $4 or $500 per person per flight, to have a subsidized flight when you could drive 70 minutes, 80 minutes, and have access to a ton of flights. Again, it is priority. Is it priority for us to continue to spend money on a small group of airports, 36, that in no way pay for themselves, that are readily accessible throughout the country to major airports, and spend the kind of money we are spending? Another amendment says if you have less than 10 emplanements a day, we ought to think about whether we are subsidizing Essential Air Service. All these amendments are saying is, will we make the tough decisions. We can't do everything we want to do. Is it nice that we have an Essential Air Service Program so some people don't have to drive an hour? I guess so. What are we willing to sacrifice to get our house in order? These are little bitty amendments that will send a wonderful signal to the American public that we get it, we absolutely get it. And because we get it, we are going to make choices about priorities. We are going to enhance the airport trust fund. We are going to enhance the airport improvement program because we are going to take lower priorities off the board, which is exactly what they want us to do. They want us to focus on the big things, the important things, and they want us to cut the spending that is not absolutely necessary. I can tell my colleagues, it is not absolutely necessary that we subsidize some of these smaller airports that are very close to regional airports or have less than 10 passengers a day. It is not absolutely essential. Would we ask some Americans to sacrifice? Yes. But do you know what will happen? We will all have to sacrifice before we get through this. The problem is the resistance in this Chamber and in this city. We don't want to make the hard choices. It is disappointing that we have not done that. We will have to do that. And we are either going to do it or somebody from the outside is going to tell us what we are going to do. Then a fifth amendment--and I know the chairman will be against this amendment because it is his program that I am trying to eliminate--in the year 2000, we created another program called the Small Community Air Services Program. This is an amendment to repeal that. It was geared to help smaller communities enhance their air service in addition to Essential Air Service; in other words, make it more effective, to try to promote utilization, which is a good idea except it is not working. When we see the funds from this program, after the grant is over, do you know what happens? The airlines leave. They don't stay. They leave. So we are kind of spending money in a market that won't sustain what we are trying to put there, and then we are putting more money on top of it to try to promote it. When it doesn't work, what happens? We lose the Essential Air Service anyhow. It has happened in Oklahoma. In this day and time that we live, we have to have an FAA bill. We can't continue to not have an FAA bill. Even if my amendments are voted down, considering that they are going to get a vote, I will probably support this bill. But it should be noted that we haven't gone far enough. We haven't made all the tough choices we need to make. I am highly disturbed that we take amendments that are absolutely germane and say they can't be offered because a time agreement, even though it has been agreed to, isn't disagreed to yet because the Senator from Vermont isn't on the floor. I am going to offer the amendment and let the chairman object. Then I will utilize the procedures that are available to me as a Member of the Senate. I ask unanimous consent to set aside the pending amendment and call up amendment No. 91.

Mr. COBURN. Then I will continue with my objection.

Mr. COBURN. Well, if the chairman will assure me I will have the opportunity to, No. 1, debate Senator Leahy's amendment----

Mr. COBURN. Thank you. Let me confine my remarks for a few minutes to how I see where we are from my perspective. My hope is that I can offer some amendments, at least get them pending, and then discuss with the chairman--I just discussed them with the ranking member--the disposition of those. I wonder whether the chairman has any comments on that.

Mr. COBURN. I told them I would be happy----

Mr. COBURN. Mr. President, is there a pending amendment?

Mr. COBURN. I told Senator Leahy last night that I would be happy to lift my objection once my amendments were pending, and we can have a debate on his nongermane amendment.

Mr. COBURN. I thank the chairman for his words. I will take him at his word and work with him and allow him to look at some of these. There are only two airports in West Virginia that this would have an impact on. Both of them are less than 75 miles from the regional airport. They both have minimal emplanements daily. They are over 10 but not far over that. The point is, we ought to help who we can help, and it ought to make economic sense. They are not targeted because there are 36 airports in here, actually, where the average American would say, this is nuts to spend the kind of money we are. I thank him for the time. I suggest the absence of a quorum.

Mr. COBURN. I ask unanimous consent to set aside the pending amendment and call up amendment No. 81.

Mr. COBURN. I thank the chairman. I will go on and allow him to object to further amendments I have so it will be in the Record that I did attempt to offer them. I ask unanimous consent to set aside the pending amendment and call up amendment No. 80.

Mr. COBURN. I ask unanimous consent to call up amendment No. 82 and set the pending amendment aside.

Mr. COBURN

Mr. COBURN. Mr. President, I submit the following notice in writing: In accordance with rule V of the Standing Rules of the Senate, I hereby give notice in writing that it is my intention to move to suspend rule XXII, including germaneness requirements, for the purpose of proposing and considering the following amendment no. 80 on S. 223.

Mr. COBURN. Mr. President, I submit the following notice in writing: In accordance with rule V of the Standing Rules of the Senate, I hereby give notice in writing that it is my intention to move to suspend rule XXII, including germaneness requirements, for the purpose of proposing and considering the following amendment no. 81 on S. 223.

Mr. COBURN. Mr. President, I submit the following notice in writing: In accordance with rule V of the Standing Rules of the Senate, I hereby give notice in writing that it is my intention to move to suspend rule XXII, including germaneness requirements, for the purpose of proposing and considering the following amendment no. 82 on S. 223.

Mr. COBURN. Mr. President, I submit the following notice in writing: In accordance with rule V of the Standing Rules of the Senate, I hereby give notice in writing that it is my intention to move to suspend rule XXII, including germaneness requirements, for the purpose of proposing and considering the following amendment no. 64 on S. 223.

Mr. COBURN. Mr. President, I submit the following notice in writing: In accordance with rule V of the Standing Rules of the Senate, I hereby give notice in writing that it is my intention to move to suspend rule XXII, including germaneness requirements, for the purpose of proposing and considering the following amendment no. 91 on S. 223.

Mr. COBURN

Mr. COBURN. First of all, let me thank my colleague from Alaska. As somebody who has been working on areas of fiscal management in our Federal Government for the last 6-plus years, this is one small step. Whether it saves $500 million or whether it saves $1 billion, it is important that America knows we need to do this 1,500 more times. We hear a lot in the press now from the Republican appropriators, the Republican budgeteers, about the battle of how much to cut. It is the wrong language. The deficit is $1.5 trillion this year. It was $1.4 trillion last year. We have tons of areas, as my colleague knows full well, as does our former colleague, the Senator from Wisconsin, Russ Feingold, where we don't effectively utilize the money that has been given to us or that we are borrowing against our kids' future. So this is a great start. We need to do this every day on every bill that comes before us. We can find it. We have identified 50 sets of duplication within the Federal Government, and they are not small duplications. There are 49 job-training programs across 9 different agencies. There are 105 science, technology, engineering, and math programs--something the President, in his State of the Union Address, said he wanted to enhance. We don't have a metric on any of them. We already have 105 programs. We are spending $18 billion on job training, and we don't know if it is working, and we don't know if the people we have trained have gotten jobs in the areas in which they were trained. So I am excited about my colleague joining with me. The hope is that we can set a trend so that with every bill that comes out, we will start looking. By the way, we do have coming from the Government Accountability Office the first third of all of the government programs. When we inquired 2 years ago to the Congressional Research Service and to the Office of Management and Budget and the GAO, we said: Give us a list of all the programs. Do my colleagues realize that nowhere in the Federal Government do we have a list of all of the programs where we spend money? We are highly critical of the Defense Department because it can't pass an audit, and we rightly should be, but we can't pass an audit because we don't even know what we are doing. So this should not be controversial at all. It should save us close to $1 billion when it is all said and done, and that is $1 billion we won't borrow from the Chinese. All we have to do is do that 1,500 more times. The fact is, we can. We are like that little engine. We can. We can get up that hill. But what it is going to take is reaching across the aisle, as the Senator from Alaska and I have done, and saying: Here is an area of common ground, it is based in common sense, and it is something that should be done and should be done now. Just to show how silly this is, the data shows that in Atlanta there is still money for the 1996 Olympics. Fourteen years ago, there was $2.7 million sitting in a bank account. They can't spend it because the Olympics has already occurred, but we still have that money out there. That is the kind of silly stuff that happens when the Federal Government reaches into areas where it shouldn't be reaching. What we can do--not to lay blame, not to say it is about earmarks or not about earmarks, but here is a commonsense solution that says: Here is a way to free up $1 billion or $500 million. If it is $500 million, great, but here is a way to do that. I wish to also take some time on the floor now to elucidate that the President's fiscal commission outlined $4 trillion over the next 10 years we could eliminate that would go a long way toward starting to solve some of our problems. So my hope is that with this amendment, we will start a trend where we can grab hold of and capture the things that make sense, that most Americans will never miss, and if they do miss it, it is because they are going to get something better instead and more efficient instead, and we start down this road. This is a great start. I congratulate my colleague for his initiative in bringing this back up. What we need to do now is get on the phone and get our colleagues in the House to do the same thing and make sure, when this bill goes through and this amendment is adopted, it actually happens. Don't forget that the Bush administration wanted this to happen, and so does the Obama administration. Think about the amount of labor we are spending taking care of details on things that can't get spent or won't be spent and the amount of man-hours that goes into that. I just thought I would finish with one of the recommendations of the fiscal commission, which is on the Federal workforce. There is a wonderful article that was published by Iain Murray on February 3 about how many Federal employees we have. It is easy for us to think about the fact that when we count true--just true--Federal employees, it is 2.8 million. But that doesn't come close to the actual number of employees the Federal Government has. When you add up what is actually there and you add in postal employees, you add in military, you add in contractors, we are at 11 million Federal employees. We have a great Federal workforce. There are a lot of areas where we can be efficient and downsize. We don't have to lay anybody off; we can just not add. What we can do is, through attrition, markedly decrease the number of Federal employees we have, which will be that second, third, and fourth billion dollars. The other thing the Commission recommended, which the Obama administration embraced, was a freeze on salaries, but most of us don't recognize that we have $3 billion owed right now to the IRS in back taxes by Federal employees that has already been adjudicated. So there are all sorts of things we can do. We have lots of ideas. My pledge is to work across the aisle with our colleagues to try to find one of these every day or one of these every other day. If we do that together, we don't have to borrow 40 cents out of every dollar we spend in this country. We can take it down to 20 or 15 or down to zero so that we can, in fact, ensure the future for our children. Again, I thank my colleague, and I yield the floor.

Mr. COBURN. Mr. President, the Federal Government has $950 billion worth of property it is not using right now. We are spending $9 billion a year taking care of it, and we have a budget gimmick that says an agency that needs a new building, because we are going to account for the cost of that building in the year in which they buy it and charge it all to the agency--what are we doing? We are leasing buildings. I guarantee we could own them much more cheaply than we could lease them. What we should be doing is changing that and getting rid of the excess property, lowering our cost to maintain it--there is 9 out of the 1,500 we have to do, right there, if we would just do that--and then change the way we purchase buildings for the Federal Government so the agency can own it instead of leasing it because it costs, over the life of the building, about twice the lease.

Mr. COBURN. Mr. President, I suggest the absence of a quorum.

Mr. COBURN

Mr. COBURN. Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. COBURN. Mr. President, I have come to the floor today to talk about the amendment Senator McConnell brought forward in terms of repealing the health care bill. I am probably going to approach this differently than a lot of my colleagues have. I do not doubt that the intent of what was passed a year ago last December was well intentioned, with the thought of solving health care problems in this country. My experiences, as a physician for 25 years, and as a manufacturer in the medical device field for the 10 years before that, gives me a little bit different take on what the consequences are associated with this bill. During that hardy debate we all had, I made some claims that people doubted in this Chamber which have become absolutely apparent and true. Costs are going through the roof, faster than we thought; portions of people cannot tolerate the plans, so we are giving them exemptions because it will not work in the business model to keep people covered but, most importantly, what is getting ready to happen is what happens between a patient and their access and their care and their provider. As well meaning as the bill was, the destruction of that aspect of health care will cause us to rue the day we put into motion what we are putting into motion. Let me explain. Most of the doctors in this country became very interested in this health care bill, and rightly so. They are the ones who are going to be impacted, along with their patients, because they are the ones delivering the care. When you poll those doctors, what do you find, now that they actually know what this bill is going to do? Well, some pretty significant statistics have come out--one by Thomson Reuters--where two-thirds of the doctors in this country absolutely believe the care of their patients is going to suffer as a consequence of this legislation. Think for a minute if you are an individual needing to access care and we are in 2014, 2015, and the Advisory Payment Board of Medicare is intact. We also know what the Medicare trustees have said about that, that when this is fully impacted, the payment under Medicare--this is a very important point--the payment under Medicare will be less than the reimbursement for Medicaid. So all of a sudden who was your family physician or who was your surgeon is no longer there. You see, this bill is about whether you can walk in and have the attention and care of somebody dedicated to you, who has your best interests at heart in terms of your health. What we are moving to is somebody who is going to have their best interests of survival at heart and your interests second. That is the real tragedy of what is happening with this bill and the implementation of it. Not only are we going to have payments reduced in Medicare--that is the only way the bill works, by the way; it is the only way we can ever get out of the jam until we address fixing Medicare--but 55 percent of the specialists in this country today will not see Medicaid patients at the reimbursement rate we have, and we are going to have a reimbursement rate for Medicare lower than Medicaid. Let me give you another example. What we know on Medicaid is, if you have no insurance and you go to an emergency room with a significant illness versus if you have Medicaid and you go to an emergency room with the same illness, the outcome for you with no insurance is better than the outcome for you with Medicaid. That has been repeated in four different studies now, and we are putting 18 million people into a system who are not going to have access to the best doctors because the payment is so low that there is a loss every time you see a patient. So describe to yourself for a minute what happens to the mother who has three young children and has their 4-year-old all of a sudden sick with a fever, and there is no primary care doctor available under the 18 million new people who are going into Medicaid, and this child does not get seen for 72 hours. The mother thinks: Well, I will wait the fever out. I don't have a doctor I can call. I will wait the fever out. When the child gets to the emergency room, because there was not a primary care doctor for that Medicaid patient to call, what do they find? They find the 4-year-old not with otitis media any longer, but with the early stages of meningitis. What was a simple, treatable disease--because access, even though guaranteed, was denied because there are not the available resources to care for that child--the child ends up with a very complicated hospital stay and potentially the loss of hearing or brain damage. Those are the real consequences of what we are talking about as we put 18 million people into a Medicaid system. We have had several Senators today talk about the cost and the gimmicks. I am not going to do that. But I want to talk about the real issues. The one place we failed in health care is we did not fix the real problem. The real problem is, everybody's health care costs too much. We did not ask the right question: How do you drive costs down? Even when you go through all the numbers that have been given by CBO, Medicare trustees, Medicaid trustees, and outside studies, what we know is, what we did not do is drive any costs down. In fact, in the short term we have actually driven costs up. So how do we do that? The way we do that is put some responsibility on both the physician and the purchaser of health care for the cost. It is human nature. If I gave you an insurance card for your groceries, and once your deductible was met all you had to pay was 20 percent of that cost from then on out, your diet would significantly improve in terms of the quality and price of the products you buy. That is all in our human nature. What we have failed to do is to address the real cost drivers. That cost driver is: There is no connection with my purchasing of health care with the actual payment of health care. How do we know if we connect it, it works? Go to any place in the country that has Amish folks. They do not have health insurance--none of them. They do not buy health insurance. What do they do? They are grand consumers and very discretionary consumers of health care because they come forward and they want to know what they are getting and what it costs before they buy it, every time. I have delivered over 500 Amish babies, and there was not one time I wasn't asked at the time the patient came to see me: What is the price for this? Will you take a cash payment up front so I can buy for cheaper? Are there some other places where I can get the tests done? Every test I ordered, I would be questioned on whether they absolutely needed the test. They were discretionary purchasers and very sharp in their discretion on how they wanted to pay for health care. Consequently, their cost for the same thing was 40 percent less than anybody who walked in with insurance. So we have totally missed this connection of market forces allocating scarce resources by making discerning consumers out of the purchasers of health care. We have gone exactly the other way. We have taken people who are at 133 percent of poverty and said: You are going into Medicaid, and by the way, you can't buy private insurance even if you want to. You have to be in Medicaid--a far substandard health care system. All the studies show the outcomes are poor, even after you equate for social disparities. We are going to put 18 million into that program, and we are going to have a shortage of over 100,000 primary care doctors in this country in the next 10 years. So who is going to see them? Let me give another example. It happened this weekend. A patient--90 years of age--severely bent over from kyphoscoliosis, bad aging and kyphoscoliosis, is running a fever and can't breathe well. She goes to the ER. She had seen a physician on Friday. She had a chest x ray, and no pneumonia showed. She goes to the ER that night. She has a pulse ox of 81 percent. Normal is 93, 94 percent. They put her on oxygen, change her antibiotics, and send her home. Well, what happened? Had we not interceded--I personally as a physician making a call to another physician--she would be dead by now because what she had was a full-blown, raging pneumonia and restrictive lung disease, but she was sent home from the ER because a physician-- not a doctor--a physician did not see her. So consequently she goes back to the ER the same night and is admitted to the hospital. They take a chest x ray, and all of a sudden they see this full-blown pneumonia. She had all the symptoms, but the person seeing her in the ER didn't have the experience to make the judgment. So is that really what we want? We want substandard care, so somebody can go home and die versus coming to the hospital? Today, she is 200 percent better. She is eating. Her pulse ox, now on room air, is 91 percent. We actually saved her life because a real physician put hands on a patient and made the right diagnosis. But we are going to put people into a system where that doesn't happen because we are going to use physician extenders. That doesn't mean they are bad; they just don't have the same experience, and people die when they don't have the same experience. But we are going to inflate the utilization of less than a physician to care for the vast majority of these people who are going into Medicaid. These are real examples of what the consequences are of what we have done. As I started, I said I don't doubt the intent of my colleagues in terms of what they were trying to get to, but the biggest disease Washington has is fixing the wrong problem. We have expanded health care access under this bill, but access doesn't mean you are going to get care. And when you add 18 million people to the Medicaid rolls, let alone what is going to happen to the States, ultimately, with the cost on the maintenance of effort where they have Medicaid now and we are going to go to 133 percent, what you have done is put the States in a pinch, and they are in a pinch already. So my question to my colleagues is, Where are the things that drive the costs down? Where is the discerning consumerism that allocates scarce resources in the most effective way? In this bill, it is not there. Nowhere is it there. Now, what is there? What is there is a tremendous amount of new taxes. There is $52 billion over 10 years on employers who fail to comply with the insurance mandate; 40 percent excise tax on high-cost health plans, $32 billion; ban on purchase of over-the-counter drugs from somebody's health savings account, $5 billion; increased Medicare tax on wages of small businesses, nine-tenths of 1 percent; a 3.8- percent surtax on investment income, and that is $210 billion; increase from 7.5 percent to 10 percent of income the threshold after which you can make a medical deduction; $2,500 annual cap on flexible spending account contributions--and I could go through this and through this. The point is, we are increasing spending on health care by $2.6 trillion after this is truly in play. Also, the gimmickry in terms of accounting and the problems associated with that have been discussed on the floor. One of the things that is there that concerns me as a physician, getting back to talking about patients, is cost comparative effectiveness. It was really cheap to send that 90-year-old person home. There was an ER visit, a little bit of oxygen, a change in antibiotics. That was really cheap. Comparative effectiveness would have said: Oh, that is OK--except she would have been dead in 24 hours. Every physician who is maintaining their license or their specialty certification studies comparative effectiveness every day. They read it in the journals. They do it to get recertified. They know the comparative effectiveness. What they don't know is that we are going to mandate what they will do, what is the cheapest--not what is the best, what is the cheapest. Well, I will tell my colleagues, if you look at heart disease in our country, if you look at cancer cure rates in our country, if you look at recovery rates from massively serious illnesses in our country from both trauma and otherwise, what you will see is the highest rate of recovery in the world. We have the highest 5-year survival rate on almost every cancer by 20 or 30 percent over every other system in the world. Do we really want to take that away? In 2003, I was diagnosed with colon cancer. I had metastatic colon cancer. I am so thankful for the health care system we had that generated new devices, that incentivized great care, and after a major surgery where half of my colon was taken out, radical lymphadenectomy was carried out, and 6 months of chemotherapy, I stand before you today, 7 years after that. I want to tell you, had I been in England or Canada, my cure rate would have been about 35 percent. Do we know what it is in this country for somebody with metastatic colon cancer? It is nearly 70 percent. Now, what created that? What gave us the technology to do that? It is because we looked at the best clinical effectiveness, not the best price. We said: How do we best and most effectively get an outcome of cure? This bill goes the other way. This bill is going to be a mandate from Washington on what your doctor can do for you, and it is also going to mandate from Washington what price should be paid. There is no question that, according to the trustees for Medicare, for us to maintain what has been put in this bill, Medicare reimbursement rates will fall below Medicaid rates. Do we really want that to happen? I will tell my colleagues, for those in my condition, those people who are diagnosed today with colon cancer, you don't want that to happen. Now, how do we get the cost down? There is no question that there is tons of waste in our health care system. We have not attacked in the way we should attack--and I can say as a practicing physician that I wasted money caring for people because I didn't concentrate on that individual because that individual wasn't paying the bill. Some nebulous insurance company was paying the bill. Some government program was paying the bill. But when somebody such as an Amish patient looks you in the face and you know that what you spend of their hard-earned money is going to come directly out of their pocket, all of a sudden the other obligation of a physician jumps up: How do I do this in the most efficient and effective way that still gives the best outcome? And we have totally missed that. The most personal of all interchanges between humans besides those within a family are between patients and their physicians, and we are going to interrupt that. We are going to undermine it, and we are going to undermine it because somebody from Washington is going to be looking and saying: Did you do it the way we said to do it, Doctor? Now, what is the doctor's oath? Is it to do what Medicare says or is it to do what is in the best interests of the patient? So that is the rub. That is where we are going with this program. So what we are going to have is, first of all, we are going to have tens of thousands of physicians retire over age 55--our best, most experienced physicians. They are leaving. They are not going to play this game. And then we are going to give physician extenders the role as primary care. They are very good in what their limited knowledge will give them but not anywhere compared to a full 8 years of medical training, including residency. They have 2 years. And then we are going to treat all of these people. What do we think the cost of that is going to be in terms of lost lives, in terms of delayed diagnosis? Delayed care is denied care. What good is it if I have Medicaid and I can't see a doctor? So the problems are very real with this bill, and I don't say that as a fiscal hawk. I want to fix health care, and I want to drive the costs down. And we can drive the costs down $300 billion or $400 billion a year. Thomson Reuters did a study. I talked about it in our debate last year. The fact is, we know that over $580 billion a year is blown in health care. That is enough to cut everybody's health care costs 20 percent. But we didn't address any of those issues. Not one of the issues that Thomson Reuters has brought up that said, here is what is wrong, here is why health care is more expensive--we didn't address those in the health care bill that was passed. Yet we wonder why we are out here wanting to change this bill. It is not so we can say: You did it wrong; it is because we really care, as you do, that we have to fix the real problem, and this bill didn't fix the real problem. So I hope my colleagues will take in the spirit that it is intended-- that we don't believe we have done anything except expand coverage under a very broken system that is highly inefficient, that tells people they are going to have care, but they are not going to have care, and those who have a doctor are going to be told by the Federal Government what care they are going to have. It is exactly the opposite of what we should have done, and we did it in haste. We know there are 1,600 new sets of rules coming, of which about 100 are through. We have another 1,500 to go. CBO says that is $100 billion in costs just to implement all this, which was never even considered in the cost of this bill. That doesn't consider the cost of complying with all of the new rules and regulations. My time is up. I will be back to talk on this again. My hope is that--now we have three physicians in the Senate and we have all seen the same thing. I am a primary care OB, one is an ophthalmologist, and one is an orthopedist. We pretty well have it covered. What we have done is not going to work. We are going to be sorry we did it. But do you know who will be the most unfortunate receivers? It is the people who think they have care but don't, the people who get seen by less than qualified individuals for the care they need, and we are going to pay twice what it should cost. I yield the floor.

Mr. COBURN

Mr. COBURN. Mr. President, the Constitution of the United States is an amazing document. Every day I appreciate the foresight of our Founding Fathers who knew that future Presidents, of any political philosophy, would seek to expand their power and try to impose their will over the legislative branch, the branch closest to the citizens of the United States. For this reason they added an important clause in article 2, section 2 that says ``He shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur;'' Negotiators for the Strategic Arms Reduction Treaty on both sides know the terms of our Constitution, which predates both the Russian Federation and the Soviet Union it replaced. However, as the Senate considered the Strategic Arms Reduction Treaty, or the START treaty, supporters of the treaty seemed to say that the Senate should abandon its role of advice and just focus on consent. It was repeated many times that any change, no matter how minor or no matter how much it improved the treaty, would be considered a treaty-killer as further negotiation with Russia was inexplicably taken off the table as an option. The reasonable amendments offered by Republican Senators were all rebuffed. The supporters of the treaty repeated many times how reasonable the amendments were but that the treaty was not the appropriate time to be debating such matters. Authors of amendments involving ensuring a robust missile defense, improving verification to prevent Russia from cheating, and merely mentioning the existence of tactical nuclear weapons were all told that another day is the best time to discuss those matters. However, one of the greatest threats to United States national security is the acquisition of a tactical nuclear weapon by a terrorist organization. Since Russia has a preponderance of the world's tactical nuclear weapons, how can it be that a treaty dealing with nuclear weapons control is not the time to discuss this issue? Supporters of the START treaty say that after it is ratified the President will be able to go and negotiate further agreements with the Russians on matters important to the United States' interest such as the tactical nuclear weapons. However, both opponents and supporters of the treaty know that there is no intention of this administration to pursue follow-on nuclear agreements with the Russian Federation. There are several reasons for this. We now have no leverage with the Russian Federation since they have already gotten a treaty favorable to their interests. Further, we will be pressing the Russians on other issues impacting our national security such as sanctions on Iran. Supporters of the treaty believe that Russia will be more amenable to our requests when history shows that Russia will act in their interest and are not concerned with existential threats to our national security. Finally, one of the purposes of any arms treaty is to clarify and inform signatories to the treaty about capabilities and intentions of each side. However, the new START treaty neither clarifies nor informs anyone about the United States' capability and intentions with regards to a national missile defense program. It is clear that the negotiators wanted to avoid this difficult topic knowing that Russia opposes the concept of the United States being able to defend itself from a rogue missile attack. However, by avoiding the topic completely, Russia is forced to consider the mixed messages of the Obama administration withdrawing missile defense capability from Poland and statements by administration officials and Congress calling for a robust four-phase missile defense program. The treaty as written can only cause further instability and confusion on the critical issue of missile defense between the United States and the Russian Federation. Clarifying amendments from Republican Senators regarding missile defense and the United States' intention to deploy technologies against all four phases of ballistic missile flight would have helped the treaty, not killed it. Instead, the lone statement on missile defense in the preamble of the treaty clearly implies that the United States should limit its missile defense in an attempt to limit the need for offensive missiles. The United States has no intention of doing so as it is a national security threat for us to ignore the dangers posed by North Korea and Iran in this area. Because of these many reasons, I voted against the new Start treaty. While it did pass over my objections, I hope that future Senators will not use the debate we just held in this lameduck session of Congress as precedent to abdicate their constitutional role for international agreements.

Mr. COBURN

Mr. COBURN. Mr. President, I wish to spend a short time addressing the remarks of my friend from Iowa.

Mr. COBURN. Mr. President, the situation we find ourself in is that no appropriations bills came to the floor. We did not control that. If that had been under our control, I assure you they would have come to the floor--and they should. No matter who is in charge, they should come. I think he agrees with that. But I will address the greater issue we have in front of us. Our Nation has a very short time with which to reassess and reprioritize what is important in our fiscal matters. That period of time, I believe, is shorter than many of my colleagues believe. But I have not been wrong in the past 6 years as to where we are coming. I have been saying it for 6 years. We are now there. The fact is everything is going to have to be looked at--everything-- every project, for every Senator, every position, every program--if we are to solve the major problems that are facing this country. We all want to help everybody we can, but the one thing that has to be borne in mind as we try to help within the framework of our supposed limited powers is there has to be a future for the country. The things that are coming upon us in the very near future will limit our ability to act if we do not act first. I take to heart my colleague's very real concern for those who are disadvantaged in our country. It is genuine. It is real. We are going to have a choice to help them or we are going to have a choice to make a whole lot more people disadvantaged. What we have to do is try to figure out how compassionately we can do the most we can do and still have a country left. That is the question that is going to come before us. I have no doubt we will have great discussions over the next few years on what those priorities are. But we cannot wait to make those priorities. We are going to have to squeeze wasteful spending from the Pentagon. We have no choice. We have no choice with which to make the hard choices in front of us. And it does not matter what happened in the past. What is going to matter is what happens in the future and whether we have the courage to meet the test that is getting ready to face this country. There is a lot of bipartisan work going on right now behind the scenes in the Senate planning for next year to address those issues. I say to my colleague from Iowa, the way to have the greatest impact on that issue is to join with us to, No. 1, agree with the severity of the problem and the urgency of the problem, and then let's build a framework on how we solve it, knowing nobody is going to get what they want. Tributes to Retiring Senators Russ Feingold Mr. President, I wish to take 2 more minutes to pay a compliment to one of my colleagues. When I came to the Senate, I visited almost every Member of the Senate on the other side of the aisle. I had a wonderful visit with the Senator from Wisconsin. We actually--although we are totally opposite in our philosophical leanings--had a wonderful time visiting together. Senator Feingold is my idea of a great Senator. I want to tell you why. I left that meeting, and about a week later, I got a note from him first of all thanking me for taking the initiative to come and meet with him, but also a commitment that he would always be straight with me, that when he gave me his word and handshake, it would always be that way, and that I could count on him standing for what he believed in but knowing he would do the things we needed to do to get things done. My observation in the last 6 years in this Chamber is I have watched one man of great integrity keep his word and hold to his values through every crisis and every vote. And every time it was taken where we had to come together to do something, this gentleman kept his character. He kept his word. He fulfilled the best aspects of the tradition of the Senate. Although I often--most of the time--am on the opposite side of issues from Senator Russ Feingold, I want to tell you, he has my utmost admiration and my hope that more would follow his principled stand and his wonderful comity as he deals with those on the other side of the aisle. I yield the floor.