Thomas Coburn

Mr. COBURN

Mr. COBURN. No problem there. Is the Senator aware that the foreign ops appropriation increased by 11 percent in 2009 and 33 percent last year? Yet the Senator is saying we can't trim 5 percent from that budget? Am I hearing the Senator correctly? We increased it 46 percent in 2 years, and we can't cut 5 percent?

Mr. COBURN. Would the Senator yield for a question?

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

Mr. COBURN. No. To answer the Senator's question, we do not even know how many duplicative programs there are out there. These are the 640 we found looking over a 4-week period. But when we asked GAO or the Congressional Research Service about this, what they say is the task is too big. They do not even know if they can accomplish the task, which goes to the enormity of the problem we face. I mentioned on the Senate floor earlier, we have a markup tomorrow in the Judiciary Committee for a new program, and it is duplicative of an existing program. But those offering the amendment do not even know it. So it shows we have to stop and reassess. Part of this amendment is creating a mandate that the GAO has to advise us on that.

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 President, I ask unanimous consent the order for the quorum call be rescinded.

Mr. COBURN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with.

Mr. COBURN. Mr. President, I ask that the amendment be divided in the form which I now send to the desk. I ask at this time that division I of the original amendment be made the pending amendment.

Mr. COBURN. I have the floor.

Mr. COBURN. Madam President, while the Parliamentarian is doing the work that is necessary at this time, I thought I would spend a few minutes talking about this amendment in the interest of saving some time. We have a significant problem in front of us as a Nation. We have before us an underlying bill that raises the debt that nobody in this room, save the pages, will ever pay a penny toward reducing--nobody except the pages and their generation will pay a penny toward reducing. This request for increasing the debt limit of $1.9 trillion, I remind my colleagues, is $200 billion more than the entire Federal Government spent in the year 1999, 10 years ago. So we, in one fell swoop, in 1 year, we are going to increase the debt by $200 billion more than what the entire Federal Government spent 10 years ago. The whole purpose behind this amendment is a wake-up call to say: Wait a minute, the Congress, in the last 2 years, under its leadership, has increased spending 11.4 percent in 2009 and 11.4 percent this year, not counting a stimulus bill and not counting omnibus bills that were not paid for because they were declared an emergency. If we add all that up, excluding the stimulus bill, we had a 28- percent increase in the size of the Federal Government in the last 2 years--just in the last 2 years. At that rate, the size of the Federal Government doubles over a 5-year period. What these amendments are designed to do is to get us doing what every American family is doing today; that is, starting to make some of the hard choices about where we have excess, where we have inefficiency, where we have duplication, and eliminate it because we should not ask the American people to take on more debt when we know we have at least $387 billion worth of waste, fraud, and duplication every year in the Federal Government. Yet that is exactly what we are doing with the underlying bill. We are taking on more debt and not doing anything about the excessive spending or the waste, fraud, or duplication. The whole purpose behind coming to the floor is to say: Can we not, in light of a 28-percent increase, cut 5 percent in terms of discretionary spending that we just jacked up five times that amount over the last 2 years? Can we not find 5 percent worth of waste? We have identified specifically 640 programs that are duplicative of one another in the Federal Government. We have identified waste. When we go to find out, when we ask the GAO or the Congressional Research Service to help us with this, do you know what they tell us? We cannot; it is too big. We cannot tell you where all the duplication is. That is our own research bodies saying they cannot tell us where it is too big. This amendment puts a stop to that. It mandates that we in the future, every year, will get a report from the GAO on every program within the Federal Government that duplicates another program and what their recommendations are to streamline or change it. The reason it is easy to borrow or easy to raise taxes is because we fail to do the hard work of eliminating the spending waste. We just had the Senator from Alabama wanting to put on some caps. That is not going to be adopted. We know it. The reason I divided this amendment is because my colleagues will take one segment of it and say: Oh, I was for cutting 5 percent out of the Federal budget, but I just did not agree with this one segment, whether it be education or somewhere else, that we should not cut, and, therefore, I voted against the whole amendment. This puts the American people in the driver's seat, as far as their Senators are concerned. We are going to get to see whether they agree that we ought to continue to waste money; that we ought to steal it from these pages and their generation and not do the hard work of making a choice and putting things in terms of priority like every American family is doing. Every American family is doing that right now. They do not have an unlimited credit card. They do not have the privilege of going to the bank when they are tapped out and say: Just give me more money, like we are getting ready to do on extending the debt limit. The other thing that is in this is leading by example. The Senators increased their budget by 5.8 percent this year. We reverse that. Most of us can easily live within the budget we had last year--easily. So we reverse the increase for the Senate back down to what it was last year. We should not ask the rest of this government to make a sacrifice that we are not willing to demonstrate by leading on the same issue. This bill can be the first step in a reality check of getting the Congress back aligned with where the American people are, as far as spending. Just a year ago, in January of 2009, the national debt was $10.6 trillion. Today the national debt is $12.2994 trillion. Forty-three cents of every dollar we spent last year we borrowed, and we are going to do exactly that or worse this next year unless we wake up, unless we come to our senses. You can have all the arguments you want, but nobody in America believes the Federal Government is not wasteful. Nobody believes it is good enough to just freeze a small portion of discretionary spending. What Americans believe is we need to cut spending. We need to cut out the waste, cut out the duplication, and cut out the fraud. We need efficiency where we can generate efficiency. We need to eliminate duplication where there is duplication. My friend, President Obama, when he was campaigning said: I promise to spend taxpayer money wisely and to eliminate wasteful redundancy. We are going to help him with that. That is what this amendment does. In 640 programs where there is duplication, we are going to allow an incentive for each department to get rid of it. We are not mandating they have to get rid of it. We are saying: You should do the review. You should take this money, and you should eliminate the duplications. What you need from us to do that, we will give you. But we are giving you the authority to do that with these amendments. Let me quote from President Obama: Too often Federal departments take on functions or services that are already being done or could be done elsewhere within the Federal Government more effectively. The result is unnecessary redundancy and the inability of the Federal Government to benefit from economies of scale and integrated streamlined operations. He is right. So now we are going to give the Senators a chance to support his statement and his position. Nothing has been done in the last year to accomplish that. As a matter of fact, the President sent program after program that he wanted to get rid of. He said they are not effective, they do not work, they are duplicative, and they are not efficient. What did we do? We did not eliminate a one of them. We just kept funding them. So we cannot claim that the problems lie with the President. The problems do not lie with the President. The problems lie with the elected body of Congress in not making the hard, difficult choices of putting a priority on what is most important and taking the time to do the oversight and explain to the American people why we ought to have the programs consolidated. We may have a goal we want to accomplish and help the American people with, but we certainly ought to do it in the most efficient and effective manner we can. The other reason to consider this amendment is to think about what is getting ready to happen to us. What is getting ready to happen to us over the next 10 years is we are going to accrue another $9 trillion in debt if we do not start this process with this amendment today. We are going to accrue another $9 trillion. Of that $9 trillion, $4.8 trillion of it is going to be interest. It is going to be interest costs on the debt. We are going to borrow money to pay the interest on the money that we borrow. It does not have to be that way. My colleagues will come down and say: The big problem is the entitlement programs. There is no question that is two-thirds of our problem. But the easy thing to fix now and saves billions, if not trillions, of dollars on is the discretionary portion of the budget that we do have control over. We always hear the excuse: That is not the big problem. The reason it is not the big problem is because politicians enamor themselves with people at home by spending money we do not have on things we do not need that are not truly a legitimate role of the Federal Government. The family budget is getting smaller, and the Federal Government is getting bigger. That is just exactly the opposite of what ought to be happening in this country today. Inflation is near zero, but yet we are increasing spending, like I said, 11.7 percent last year. That does not include the supplemental emergency spending and does not have any connection at all with the stimulus bill. That is what we did with the individual budgets across the Federal Government. When I come down and make the case for cutting back 5 percent of that, which ends up being $120 billion, nobody should be opining: My goodness, we are going to tear things up. But we are going to hear that. We are going to hear all the reasons we cannot do what I am proposing to do. America is not going to buy that anymore. They are not buying it anymore, and they should not buy it. The other thing this amendment will do is it will give us 30 days to come back and assess other areas where we can cut more spending. People in this body think that is hard. It is not hard. Let me give an example of where we can save $80 billion a year in one program. At a minimum, there is $100 billion of fraud in Medicare a year. We do not have an effective strategy, like any other organization outside of government, to limit the defrauding that goes on in Medicare. We pay, and then we try to chase people we should not have paid. Senator LeMieux from Florida and others have multiple ideas on how we could take that $100 billion and over the next 6 months save $30 billion or $40 billion of that. That is $30 billion or $40 billion each year over the next 10 years. That comes out to $\1/2\ trillion, which cuts down that $9 trillion in additional debt we are going to be encumbering upon our children. Last year, this country's debt grew $4.2 billion a day. We didn't do anything about that except spend more money, so this year it is going to accrue at $4.3 billion a day. That is how much we are going to spend that we don't have. Isn't it time that we start facing the situation as it is rather than the way we would like it to be? The cold hard facts are that we have a short timeframe--4 to 5 years at most--to get our house back in order. Now is the time to start. It is not next year, it is not next month; it is right now--right now, when the American people may or may not be focused on the fact that we are going to authorize an additional $1.9 trillion worth of borrowing. You can't even write that many zeros down and have a comprehension of how much it is. At the same time, we don't do anything about solving the problem. Quite frankly, Congress has a dependency issue. We are addicted. We are addicted to spending. We are addicted to the age-old adage that if I spend enough money, I can go home and tell people how great I am, not ever telling them I am spending their money and their kids' money but claiming I am looking out for them. The only way you really look out for America is to secure America into the future, and we have not been doing that. It hasn't been done under the Republican watch, hasn't been done under the Democratic watch. What has happened is the same old same old of continuing to ignore the problem and not taking the heat for making the tough choices that will put our country back on the track on which it belongs--a track that will secure a future for our children and grandchildren, that will embrace the heritage that made this country great. What was that heritage? That heritage was sacrifice. In this country, all of us--many--are sacrificing now, and many in the future are going to have to sacrifice. Others will come down to the floor and they will say: Well, Coburn, all you want to do is cut spending; you don't really want to solve the problem. Well, the first part of solving the problem is cutting the spending and recognizing that the walls don't fall down if you cut 5 percent out of the discretionary spending in our budget. As a matter of fact, very few people will ever notice $120 billion coming out of the Federal Government on these discretionary programs because they will just go to a different grant program that does the same thing and get it there. Let me go into some of the facts because many of us don't understand. Here are some examples: There are 14 programs administered by the U.S. Department of Education related to foreign exchanges and designed to increase opportunity for students to study abroad. There is nothing wrong inherently with wanting our students to study abroad, to gain that perspective and to gain that education, but why 14 different programs? Why not one? Why not 1 program and save all the administrative costs of the other 13? Why not do that? Because somebody may not have their name on a program? The fact is, nobody knew that until we discovered it in the last 4 weeks. There are more than 44 job-training programs administered by 9 different Federal agencies across the bureaucracy, costing $30 billion a year. Forty-four Federal job-training programs? Tell me why we need 44. Maybe 4 to hit different areas in different situations but not 44 and not through 9 different Federal agencies that are all trying to do the same thing and competing to throw out money. What about 69 early education programs administered by 9 different Federal agencies. Sixty-nine, why would we tolerate that? Why would we continue with the status quo? Now is the time to make changes. One of my favorites is that we have 105 Federal programs supporting science, technology, engineering, and math--105 different programs where we support that--funding over $3 billion a year. I agree we ought to encourage it, we ought to stimulate it, we ought to support it because we know we have to be competitive in the future, but do we really need 105 different Federal Government programs? The answer is, absolutely not. We don't. But because we don't know what is there, we continue to do the same. As a matter of fact, there is going to be a Judiciary markup on Thursday that has a new program in it--supposedly new--and the authors of the bill have no idea that we already have a Federal program that does the same thing. That is why the important key component of this global amendment is to make sure the GAO tells us what is out there, what we need to do, and how we need to go about it. We may need some redundancy, but we don't need 105 times redundancy, we don't need 30 times redundancy, we don't need 44 times redundancy, and we don't need 69 times redundancy. As a matter of fact, when we have all these programs, the States have to hire all these different people to understand all the different programs so they can make sure they get their fair share. We could actually save the States a ton of money if they only had one-stop shopping--if, in fact, it is a truly legitimate government function. The amendment also rescinds unobligated discretionary funds that have been available for more than 2 consecutive fiscal years. So it doesn't hurt the agencies if the money has been there and they haven't spent it. As a matter of fact, we are giving them so much money, they can't spend it all. We have seen unobligated balances go up because they can't get it out the door. And when we are pushing them to get it out the door, guess what happens to efficiency and accuracy and effectiveness of those programs. It goes way down. According to the Office of Management and Budget, at year end 2009, that is, September 30, there was $657 billion sitting in unobligated funds. Some of that is military, some of that is war funds, some of that is VA. We exempt war funds and we exempt VA. We exempt DOD, but we shouldn't because there is $50 billion a year in waste in the Pentagon that can easily be demonstrated. So we direct the GAO to identify those duplicative programs and report to Congress on the findings. Madam President, may I make an inquiry of the Chair? Has the status of our division been decided?

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

Mr. COBURN. Mr. President, I ask unanimous consent that the pending amended be set aside and I send up amendment No. 3303.

Mr. COBURN

Mr. COBURN. Mr. President, I ask unanimous consent that these letters commenting on the Patient Protection and Affordable Care Act of 2009-- the majority's ``health reform bill''--be printed in the Record.

Mr. COBURN. Mr. President. I ask unanimous consent to have printed in the Record the following letter I sent to Mr. Alan Frumin, Parliamentarian of the U.S. Senate, on January 8, 2010, regarding the ruling that occurred in the Senate on December 16, 2009, during consideration of the health care reform bill that permitted Senator Sanders to unilaterally withdraw his amendment during its reading.

Mr. COBURN

Mr. COBURN. I think the Senator from North Carolina is really going to where I am going to get to later; that is, what is the motivation for the decisionmaking? I think my colleagues on the other side of the aisle are well intended, but I don't think they are well informed about the consequences of their intentions. So if you set up the Task Force for Preventive Health Services and say you are going to rely on it, but we know they are going to make the decisions based on cost-effectiveness, not clinical effectiveness, what we are going to see is the American Cancer Society coming again and again and again because what we are going to do is we are going to cover those where it is cost-effective but not clinically effective. For 80 percent of Americans, they are not going to notice the difference, but one out of five Americans is going to notice the difference. The second area, which I wish to spend some time on because we have actually modeled it after England, is cost comparative effectiveness. We ought to talk about what is comparative effectiveness research because there is nothing wrong with the research. It is health care research comparing various drugs, devices, and treatments head to head, and the whole goal of that is to find out what works best and what costs the least. The assumption in this bill is, we can have 24 or 36 people in Washington decide that. In the Framingham studies they have been running for over 50 years on heart disease, we still don't have the answers and we have been studying it for 50 years. But we are going to be making decisions on cost, not on clinical effectiveness, which is going to limit your ability to have what you and your doctor think you need. So we are going to pull out clinical experience of individual physicians. We are going to eliminate the heart of medicine, which is the combination of vast experience, gray hair, long years of training, family history, clinical history and physical exam and we are going to say: No, it doesn't matter. We are going to say: Here is the way you are going to do it. Who uses comparative effectiveness research? Well, several countries do. When I share with my colleagues the stories about how it is used, you are going to get a real vision of what is coming with this bill--a real vision. This bill creates a new agency called the Patient-Centered Outcomes Research Institute to perform comparative effectiveness research. I have already said the idea behind it is good. I strongly support medical research. I strongly support helping doctors and their patients choose the best research and the best treatment. The problem is, this bill doesn't do that. On the contrary, this bill will empower the government to decide which treatments you can have and which ones you cannot have. That is what this does. This removes the judgment of the doctor and replaces it with the judgment of the bureaucracy in Washington. It is not a hypothetical concern, it is a real-world problem. In Britain, they control health care costs by denying or delaying access to expensive therapies. That is one of the reasons this country has one-third better survival for every cancer you can imagine over Great Britain because we don't do that. As a two-time cancer survivor I am acutely aware as a patient, not as a doctor, in that I want to make sure for my family and my patients they have the best alternatives, not the cheapest, because the cheapest alternatives are the ones that take years away from your life. I am going to go through some examples. Nobody can dispute this is what is happening now and what will happen under our program. To Senator Baucus's credit, he had a bill that wasn't cost comparative effectiveness; he had one based on clinical comparative effectiveness. That is not in here. What is in here is cost comparative effectiveness. Senator Baucus knew you don't want to use cost as the main thing; you want to use clinical outcomes as the No. 1 deciding agent in how we approach health care--not cost--because if you only look at cost, nobody in this country would get a mammogram between 40 and 50. But this bill is different from what Senator Baucus had offered in his Finance Committee markup. There is an agency in Great Britain called the National Institutes for Health and Clinical Excellence. It is pronounced NIHCE. Here are some of the decisions of NIHCE in the most recent years. They have a problem in England with cost, too, and they have a single-payer, government-run system. They have the government running it, but they still can't control their costs, so what have they done? They have repeatedly denied breast cancer patients breakthrough drugs. They have forced patients with multiple sclerosis to wait 2\1/2\ years to receive new innovative treatments that people in this country are getting as soon as they are available. They have denied early stage Alzheimer's patients medication, requiring their condition to worsen before they give them the medicine. What do we know about the medicine? It works best when you have the slightest symptoms of Alzheimer's, not when you get worse. But that is the bureaucratic thinking: We will save money rather than practice good medicine. They deny life-prolonging treatments to kidney cancer patients. They denied new medicine to all but a small percentage of patients with osteoporosis and then only as a last resort. In other words, you have to about have your bones breaking by standing before you get medicine for osteoporosis in Great Britain. In this country, we have prevented millions of hip fractures through effective medicines to restore the calcium and bone matrix in seniors' bones. But we have Medicare now saying you are doing too many tests to check on that, so you can only do it every 2 years. So we are going to use rationing, and we are. They denied access to the only drugs available to treat aggressive brain tumors. They denied effective drugs to bowel cancer patients, colon cancer. Macular degeneration is something that affects a large number of people in this country. That is where the macula--the area that actually allows you to see and concentrate your vision--as we age, we have what is called cystoid macular degeneration or dry degeneration. That is a disease of the eye where it causes vision loss. NIHCE required patients suffering from macular degeneration to go blind in one eye before they could have the medicine that almost every American who has macular degeneration in this country has. She had to go blind first in one eye before you could ever get the medicine. That is a bureaucrat making this decision or a bureaucratic committee because it was cost-effective to allow you to live with one eye. Elderly patients went to court to fight for drugs to keep them from going blind. Twenty- two thousand Britains became totally blind through that ruling by the NIHCE. In one case, an 88-year-old World War II veteran and former Air Force pilot sold his house to pay for the drug after the government said they weren't going to pay for it. The Royal National Institute of Blind People said that as a result of NIHCE's decision, countless people have either been stripped of their sight or stripped of their life savings to pay for private treatment. For Alzheimer's, they ruled that three drugs, common to many people who are listening today--Aricept, Reminyl, and Exelon--were not cost- effective for patients with early Alzheimer's disease. Well, those are the only ones they work effectively on. One hundred thousand Alzheimer's patients a year were denied treatment that could have slowed the progress of their disease. The British Alzheimer's Society said this decision was disgraceful and victimized the most vulnerable in our society. Brain cancer. Gliadel and Temodal were not cost-effective for treating brain tumors and severely restricted their access to them. A 47-year-old woman sold her house to buy the drug the government refused to provide. They have been held as the biggest breakthroughs in treating brain tumors in the last 30 years. Finally, in April of the year before last, they finally relented and allowed brain cancer patients to have the drugs that were available on the market. Erbitux, very effective in resistant colon cancers. In 2006, denied. Seventeen thousand Britons a year get the sort of advanced colon cancer that Erbitux is designed for. Yet they can't have it.

Mr. COBURN. Madam President, I would just follow with one comment to my leader as far as his comments. In 2007, we passed a bill called the Honest Leadership and Open Government Act of 2007. That act requires the posting of any earmarks or direct benefits for Senators in any bill. It has to be posted. We have not seen that with this bill, though we know there are numerous and sundry specific earmarks for Members. So my hope is that sometime during this process, we will take up the violation of this very law by the leader of this Chamber in terms of ignoring it and flaunting it. What he said, when we passed it, was it was a needed change, and now we see it ignored as they bring this bill to the floor.

Mr. COBURN. I thank the leader. I want to spend my time this morning kind of talking about how you control health care costs in our country. My experience, just from my qualifications--I have 9 years of experience in manufacturing medical devices. I did that as a young man, had hundreds of employees and a fairly large business. I left that business to become a physician. The call of my life was to help people directly rather than indirectly through my medical device association. So I want to lay out the two different ways, the two different arguments for how we control health care costs because everybody in this Chamber wants to control health care costs. All the Democrats and all the Republicans do. We have 11 studies that say premiums are going to rise and one that says they are not under this bill. So that is not going to control costs. But I want to read a story that a lady from my district wrote me because I think it is very important in us considering which way we go. Dr. Coburn, I hope you don't mind a personal story, but as I listen to the health care debate, I can't help but think constantly of my middle daughter. I am convinced that Chloe would have lost her chance for a normal life, had these policies-- In this new health care bill-- been in effect two years ago. No government agency could possibly have understood Chloe's unique needs or her extremely rare condition. After a perfectly healthy childhood, my seventeen-year-old showed me that her left arm was twitching and wouldn't stop. Within weeks, the entire left side of her body was jerking constantly, every waking moment of every day. Her MRI revealed more than one periventricular heterotrophic nodule-- That is a growth around the ventricular system, the fluid system of the brain-- but her first two neurologists weren't sure there was a connection between the [changes in her movement and the movement disorder and the symptoms and the nodules]. They certainly had nothing useful to offer in terms of treatment. But I made the rash promise to my daughter that someone, somewhere, knew what to do, and that we would not stop looking until we found that person. Unlike mothers in a government run system, I was free to research the options and apply where I wanted. Our search took less than three months. Chloe's pediatric movement disorder specialist at Mayo Clinic called her condition ``unique'' and unclassifiable. He had to debate her case with his neurology team, but in the end they were willing to try an unprecedented series of brain surgeries. Chloe was desperate to live a normal life again, so my husband and I agreed, though perhaps you can imagine what an excruciating decision that was. Today, Chloe twitches a little, but anyone who didn't know her history would think she is just fidgeting. She is an honors linguistics student at OU, and she even takes dance lessons. She recently started driving again. She said once, ``Mom, without the surgery, I would be strapped into a wheelchair now. I know that Chloe would never have had the unique care she needed, if we had been required to petition a government agency for permission. A less dedicated person than her subspecialist would have tried to classify her condition and restrict her to known treatments. In fact, other subspecialists wanted to make those same restrictions. Chloe's doctor learned how to treat her by spending a great deal of time with her, by talking to her and to us for hours at a time, and by observing her in multiple contexts. I fear for the next mother whose child has an unclassifiable condition, and whose treatment is planned by a faraway committee with a diagnostic manual open on the table. Chloe won't be in that manual. The thing that keeps people from getting health care in America today is the cost of health care. We have had all sorts of attempts of, how do we do that? We have had the Massachusetts model, and, as entered into the Record yesterday, they have insurance reform. Almost everybody in Massachusetts is covered. Yet last year 21 percent of those people who were covered could not get care because they could not afford the deductibles and copays. So expanding insurance and expanding the model does not solve it. So you can either approach controlling costs or you can ration care. What has happened in this bill, as it comes through, is we have chosen to ration care. My colleagues are going to dispute that, but I want to offer significant evidence to offset that and discuss what is in the bill and to also discuss what is not in the bill. What is not in the bill is a prohibition against rationing, which all of my colleagues on both the Finance Committee and the HELP Committee voted against, which means you are for rationing if you vote against, a prohibition. The leader denied an amendment on the floor of the Senate to eliminate rationing, so we do not get to see where everybody stands. But we understand the intent. So there is no question that the way we are going to control costs is to limit your access by rationing health care. The other side of controlling costs is to incentivize the prevention of disease and incentivize payments for good outcomes when we manage chronic disease that is there in an efficient and effective way. That is not in the bill. That is not anywhere in the bill. What we have to do is incentivize an insurance company to invest in the management of chronic disease rather than to pay for the consequences of the chronic disease. That is not in the bill either. So we get two choices. Now, what do we find in this bill? We find a Medicare advisory commission. They actually dropped the name ``Medicare'' from it, but we find an advisory commission that is going to tell us how much money we have to cut from Medicare, and we either have to cut that amount or make some cuts somewhere else. We have the U.S. Preventive Services Task Force, and we have already seen during the debate on this bill when they do something that is based on cost alone--not clinical; breast cancer screening for women between the ages 40 to 50--when they do something on the basis of cost instead of clinical, we run in and jump and say no, but we are going to pass a bill that is going to totally empower that. Seventeen times in this bill is the U.S. Preventive Services Task Force referenced in what it is going to tell us what to do, and it is not going to tell us just in Medicare and Medicaid, it is going to tell us in every area what we are going to do. But because there was such a reaction to the first recommendation based on cost--and let me explain what that was. They said that if you are age 50 and over, the incidence of finding somebody with breast cancer is 1 in 1,470 people, but if you are between the ages of 40 and 50, it is only 1 in 1,910 people; therefore, it is not cost-effective. So it does not matter if you have breast cancer between the ages of 40 and 50, we do not think the government ought to be paying for your mammogram and we do not think anybody ought to have one. Well, that is fine for all those people who do not have breast cancer. It is terrible for the people who do have breast cancer and it could be found early with a mammogram. So we rushed in here and we offset what that task force did. But they are going to be doing it time and time again. And is the Congress going to truly--every time they make a decision based on cost-effectiveness, not clinical effectiveness, are we going to reverse it? We are not. So there is another proof that we are, in fact, going to use the rationing of care to control costs.

Mr. COBURN. I would be happy to.

Mr. COBURN. That is the problem with our system today. What we are going to hear them say is the insurance companies do this now. At first, for new treatments, until they are proven effective, most insurance companies don't cover them, but they cover them much sooner than Medicare does today. Today, Medicare is the last to approve the drugs. We are going to hear that is not any different than the limitations from insurance. That is true. We need to change that. But the fact is, we are getting ready to put all these people into insurance programs, and then we are going to have the Federal Government, which is just as bad or worse than the insurance company, making those decisions. I wish to finish my point on cost. We get two ways for fixing cost because that is what is keeping people from getting access. We can either ration it--and there are three methods to rationing in this bill which will be used--or we can incentivize outcomes and we can incentivize prevention and we can pay, based on the transparency of outcomes and quality. We haven't done any of that in this bill. We have said we have, but when you look at how do you prevent it--and the model is the 200,000 employees at Safeway and what they have been able to do in using their incentive systems to pay for prevention, to use competitive purchasing to reconnect the employee with the purchase of health care. I understand my colleague from Nebraska is here, and I will yield to him because I understand he was a unanimous consent request.

Mr. COBURN. I am not sure I can answer the question. But it would make it less effective in terms of supposed claims.

Mr. COBURN. Madam President, I know our leader is coming to speak, but prior to him coming, I will take a portion of my time that has been allotted to me by my side. I sat here with great interest listening to the Senator from New Mexico. He referenced the State of Massachusetts. I entered into the Record yesterday the 21 percent of the people under the plan who could not get care in Massachusetts because they could not afford the copay and the deductible. This is basically a copy or model off of that. He also discussed the fact that this shows a $132 billion savings over the next 10 years. That is provided you do not think you are going to allow any increase in doctor payments and you are not going to reverse the 21-percent cut. Madam President, my leader is here, and I will be happy to yield to him at this time.

Mr. COBURN

Mr. COBURN. They will go to Thailand or India.

Mr. COBURN. Let me finish this for a minute, if I might. Here is the summarizing paragraph: The economic reality is that no rationing of care supply will ever control costs, when the problem is demand inflation driven by popular insurance tax subsidies too sacred to repeal. Consider that when federal fiscal ``necessity'' overwhelms empty slogans,-- Our empty slogans-- scores of new bureaucracies created in [this bill] would be able to implement Draconian rationing in collusion with subservient insurance and ``provider'' corporations. The high costs, as well as the rationing powers included in the more than 2,000 pages of the ObamaCare Senate legislation are very real. Which is the point I have been making all along. I am going to spend 30 minutes tomorrow talking about the rationing aspects of what we are about to do as we pass this bill.

Mr. COBURN. I thank the Senator for holding this colloquy, and I will make one final point before I stop. I don't doubt the motivation of our colleagues on the other side of the aisle. They want us to fix this problem--the problem in health care. But the problem is cost. If you don't fix cost, and you expand the same broken system, you haven't fixed anything. You have added to the cost.

Mr. COBURN. I will be happy to yield.

Mr. COBURN. What we also know from the Congressional Budget Office is that between 9 and 10 million people who today have insurance through their employer will actually lose it. They are going to lose their insurance. That may be good or bad for them. But if you look at the incentives, the subsidy for people who do not get insurance through their employer, if you make $42,000 a year, today with your health insurance through your employer you get a benefit of about $5,749 from the tax system. But under this bill, you will be eligible for $12,500 worth of subsidy. What do you think an employer is going to do? They are going to look at their employees and they are going to say: I have to pay this penalty if I don't offer this, but it is a significantly smaller amount than what I am paying today. Therefore, I am going to make a decision to no longer offer health insurance, give my employees a small raise because the government is going to come in with $12,500 worth of subsidies to put them in a ``private'' plan inside the parameters of what is in the exchange. How many people do you think it is going to shift? What we are going to get is adverse selection. So the individual-- let's say I am working and I am making $42,000 a year and my employer decides to do that and let's say I am 35 years old and I know available to me is $12,500. Even though my earnings may go up, I am still 2\1/2\ times better off. I also know I will have to pay $3,000 or $4,000 of my own money to get that benefit. I will not cover myself because I know I can cover my little incidentals. If I get sick, they have to cover me in the exchange. So we are going to see adverse selection in the insurance market, people who are between 40 and 64 who are sick are going to pay far more for their health insurance and people who are sick who are younger than 40 are going to pay far more for their health insurance and everybody who is healthy under 40 is going to say: This is an economic bonanza for me. I am not going to buy insurance.