Thomas Coburn

Mr. COBURN

Mr. COBURN. Madam President, will the Senator from North Dakota yield?

Mr. COBURN. Madam President, I now ask unanimous consent that we have the regular order on Coburn amendment No. 4036.

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 Madam President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. COBURN. Madam President, this is a pretty simple amendment. What it says is we are going to give the Native Americans what we promised them in our treaties. We are going to give it to them in the same way we deliver security, choice, prosperity, and health care for Members of Congress. We are going to give them an insurance policy. In basics, I think my chairman agrees with it; he does not agree with the way we are doing it at this time. I understand that. What you all should know is three-quarters of the Native American population of this country lives in urban areas; it does not live on the reservation. That is three- quarters. What this does is fulfill our commitment through giving them access to quality choice and care--not substandard care, not rationed care, but real care.

Mr. COBURN. Madam President, I will be happy to.

Mr. COBURN. A large portion of them are Medicaid eligible. As a matter of fact, 27 percent of the funds that go into IHS are people from Medicaid. If they are Medicaid eligible, then they are eligible for every one of these programs. A large portion are Medicare eligible. A large portion of money that comes into IHS comes from Medicare, and they are also eligible under that. So the majority of our Native American population already have these services available to them under two other programs. The other question I would ask through the Chair of the chairman is-- there are other clinics and IHS facilities, I believe, and please correct me, that are being run well and that will be able to utilize these services for that smaller portion of Native Americans because they will have the funds because they are meeting basic core medical needs now. My amendment doesn't take that away. It just says if you are in an IHS clinic and over half of them already have these services available through another government program, why would we add that when we are not taking care of the diabetes, the dialysis, and every other thing we have? My question to the chairman is--I would love for him to consider that this is a better way to go rather than blanketly treating everybody the same and that we have to prioritize, and that by having IHS Directors make that priority--in different areas, that is true--in terms of what goes through the tribal government, what we will get is better care.

Mr. COBURN. I ask that amendment be brought up, No. 4034 be made pending, and ask for the yeas and nays.

Mr. COBURN. It does not at this time. I will give a commitment to the chairman. Under our rules, when I want to take money away from something else, I have to deauthorize it. We don't have enough money in Indian health so we have to deauthorize something else. If we get it under the budget, I have every intention of making us make a choice. I will vote for an increased authorization at this point in time right now for $2 billion. But I will also come back and say we have to find the money to pay for it.

Mr. COBURN. I would like to reclaim my time if I might. The fact is, we appropriate $280 billion a year in stuff that is not authorized right now. So we will not have any problem appropriating this money if we don't authorize it. A quarter of the discretionary budget is not authorized right now. We will not have any problem with that. My amendment says, on the areas the Senator just described, to do it only if it is geographically feasible. I recognize there are some places where we have isolated reservations and we have IHS. I am willing to put the money behind it, but I also realize more of the same doesn't get it done. So if we double Indian health care money, we are still going to have an inefficient system that will deliver care at a lower level than what you can get in the private sector. What I am saying with my amendment is, let's have both. We ought to do both. I am making a statement on the Senate floor--and the Senator will recognize, I believe, that I usually keep my word about coming back and doing what I say I will do--I will work to get the extra $2 billion, but an extra $2 billion in a broken system is not just money that is broken with IHS. I believe the chairman will agree. What I wanted to do is fix the system and increase the money, increase the choice and security that Native Americans are entitled to that all the rest of us have. The fact is, if the only place a Native American can get care is IHS, that is not freedom. That is not the promise kept in its fullest bloom. It is saying, here is the only place you can get care. If the care happens to be great, super. But if the care happens to be average and they need better, they don't have that opportunity. If the care happens to be--and sometimes we know it is, like some of the cases the chairman has presented--when it is substandard and that is the only choice they have, that is not acceptable. Let me finish my deal, and I will let you go and you can hammer me. I hope I can get you to come around. Maybe I would not get your vote. I know I will get your commitment to work toward it in the future. But I think just adding more money to IHS doesn't fix the problem. I described that earlier when I talked about 30 or 45 minutes. What this does is, it treats Native Americans like every other American. That is what this amendment does. It gives them choice. It gets them out of the prison we have placed them in that says: You only have one place you can go. And, by the way, if we run out of contract funds, even if you need to go somewhere else, you can't go. Contract funds actually have run out on average in June. So for 5 months of the year, when we need to send Native Americans somewhere else, we don't have the money to do it. So who suffers? Under this system, you would not run out of contract money because you bought an insurance policy. You have given them the average cost of an individual insurance cost with what we are spending now on care. By the way, I have another amendment where we describe what an Indian is because, in my State, we have people who are \1/512\th stepping in front of a full blood. And most people don't think somebody that is \5/ 11\th out of \5/12\th ought to be getting full pay for their health care. And in fact, there are .12 of 1 percent Native blood. We call that light blood in Oklahoma. We have whole blood, mixed blood, and light blood in our State. It actually is very complicated because what is happening now, we have tribes that have quantums and say: If you are not a quarter or an eighth, you are not eligible. But under the IHS system, from some of the other tribes who have members who are \1/ 512\th, they come down to their area and they get into IHS. So here is somebody with \1/512\th taking Indian dollars away from somebody who is a quarter or somebody who is a full blood. What we have said is: Tribes, you have to decide who is an Indian. We actually have some people who are a thousand and 24th that we are giving full blown care to in Oklahoma. They have access to care somewhere else, but they don't want to pay the deductible or the copay. So they step in line in front of a full blood. We have to change that. We have to fix that. We have to fix that because our obligation has to be to the person with the most and then come down. So if we really have restricted dollars, what we have to say is, if you are below a certain level, you have to contribute something. That is the other way that we solve this problem. That doesn't demean the heritage of our Native Americans. What that says is, the reality is, in 2016 in this country, we are going to be cutting spending all over the place because that is the year interest rises through the roof. That is the year we run out of Social Security with which to pay for Medicare. That is the year in which for the projected spending, based on revenues, based on growth even at 4 percent, we start running trillion-dollar deficits--trillion-dollar deficits. Have we ever asked ourselves why gold is worth four times more against the American dollar than it was 10 years ago? Do you think it has anything to do with people thinking we cannot pay back our debt? So this idea that we are going to have more money in the future to do more things is not going to be there. We need to come to the reality of the situation. We need to start making some of the hard choices. To me, keeping our commitment to Native Americans has to be set up now; otherwise, it is not going to happen, and the funding is not going to get increased between now and 2016. Other than what we do this year, it is going to be hard. The money is going to be hard to get, even if we get out of Iraq. We are going to get notice today on what I have been working on for 2 years, talking to the Census Bureau about that they are going to be out of control and spend a whole lot more money. I am getting ready to get notice by the Secretary of Commerce--I have a meeting with him this afternoon--that there is going to be a close to $3 billion more pickup to do something we have to do because it has been totally mismanaged-- totally mismanaged. We have been having hearings for 2\1/2\ years on it, where they have been denying it, and now they are coming to say it has been mismanaged. They are coming to agree. It is why oversight matters. Had we gotten some of the amendments through this body that we offered on the census, we would not be here. But, instead, we are going to spend $2 billion to $3 billion more because we did not pass the amendments offered based on oversight that we did in my committee. The whole goal--I am not perfect. I am not right, necessarily, on how I want to do that. I will admit that to the chairman and ranking member. But I know more money does not solve the problem on this, and unless we create real freedom, real choice, and real health care security for Native Americans, we will never have an efficient IHS system, and we will never meet the commitments that we say we have. So I will ask for the yeas and nays on this amendment. I will listen to the chairman. I do have a meeting at 2 o'clock I have to be at. Whenever the chairman would like to stack the votes, if we run others, I will be happy to work with whatever is his pleasure. Mr. President, I ask for the yeas and nays.

Mr. COBURN. I am happy to.

Mr. COBURN. I will happily vote for that. But what we have to do is deauthorize something else. I know you disagree with my thoughts on increased authorizations versus offsets. I believe we have a commitment. I believe we have a treaty obligation. I believe we have a moral obligation. But I also believe it has to be balanced with the obligation that Members of Congress refuse to do, which is to make judgments about priorities. An empty promise to authorize that is not offsetting some authorization somewhere else without coming around and doing it; tons of bills go through this place authorizing things so we can send a signal out there that we did something, knowing that we never intend to fund it. Right now we have over $8 trillion a year in authorizations. It can't be hard to find $2 billion to deauthorize to increase the authorization for Indian health. We have to have a vote, and we have to decide what that is. I will commit to the chairman, I will vote for that, as long as we are decreasing somewhere else. I am willing to go find where that is for the chairman. I will commit that I will offer an amendment to increase the spending for this in our budget. I also will commit that when the appropriations come through, although I may not vote for the whole appropriations bill because it is not going to just be for Indian health care, I will vote for amendments that will increase the amount of money that goes to Indian health care as long as it is within the budget. That is why I said my goal is to do that within the budget where we could have a debate about priorities.

Mr. COBURN. Madam President, through the Chair, would the chairman agree a large portion of people who are eligible for Indian health care service today already have these services available to them through another Federal Government program?

Mr. COBURN. Mr. President, will the chairman yield for a couple moments?

Mr. COBURN. Mr. President, every amendment I have has something to do with this bill. They are all germane, not meant to delay. I am happy to vote for cloture right now to prove that I don't want to delay this bill. What I am going to ask is unanimous consent for the regular order and discuss my amendment No. 4034, after which I will ask for a vote. Then if the leadership wants to stack votes, I am fine with that. This is a simple amendment. I know the chairman is critical of it because he thinks it is false in terms of its intent. During our budget debate, I plan on adding $2 billion to Indian health care. I also plan on making us make the tough decisions on where we take it from. We don't have extra money, so it is about priorities, about keeping commitments. I will be offering that when we get to the budget to make sure there is an extra $2 billion for Native American care, and then we will decide whether we think that is a priority as we vote on the budget and on the appropriations bills. This is a straightforward amendment. This allows tribal members to get insurance. If they want to use the IHS service, great. But if they have to wait in line to wait in line to get care, maybe they can go somewhere else. Then we are keeping our commitment. If they know that the care for a certain type of disease is terrible at IHS, they can go where it is better. We are going to put the security of our promise in real terms, and we are going to put choice, the same thing every Member of this body has, and security in health care, into the hands of the Native Americans. That is what the amendment does. The reason it doesn't cost anything is because we are going to charge IHS for what it costs. We have designed the amendment. We are waiting to see what the budget chairman does with the budget and where we are going to find this $2 billion. But I promise you, we are going to get a chance to vote on my amendment to put in $2 billion. So it is not an empty promise. One of the things we know that improves everything is competition. One of the ways to get rid of some of the waste that is in IHS and to put a priority back in is to start competing.

Mr. COBURN. I inquire of the Chair, earlier this morning I made all my amendments pending. Mr. President, I ask for the regular order on amendment No. 4034.

Mr. COBURN. Mr. President, first of all, let me thank the chairman and ranking member, Senator Murkowski, for their work on this effort. Amendments Nos. 4024 through 4037 to Amendment No. 3899 Oklahoma is the No. 1 State in the country as far as tribal members. Indian health care is an issue on which we are struggling, and there are all sorts of components for it. I am going to ask unanimous consent now to bring up my amendments numbered 4024 through 4037 as if brought up individually and ask that each be set aside so they will be considered pending. I ask unanimous consent that be carried out at this time.

Mr. COBURN. Far less than what I bring up.

Mr. COBURN. Madam President, amendment No. 4036 is a real simple amendment. What it says is we are going to prioritize the funds that go into the Indian Health Service. We have had debate all day on whether we are improving Indian health care when we add services but do not add money, and we have not done the structural reforms that need to happen in the Indian Health Service. We know the Indian Health Service is plagued by rationing on a life- and-limb basis. As to the quality of care we are offering in IHS, for some places it is great, but on average it is less than what we offer other people. Instead of fixing the problem with basic medical services, this bill includes new services. We are not funding the services we do now, and the services we are funding are not at the level they need to be in terms of their quality. This bill expands the burden of IHS to fund things that in terms of priority are not as important, No. 1, but, more importantly, most have an eligibility avenue with which to get these services through some other Government program. So by supporting this amendment, you are not denying the four new services because they are already available, just not through the IHS. This amendment would require funding go to what has already been promised to tribal members before we expand to new promises. In other words, before we add new services, let's make sure we are funding the services we are offering now and that we are funding them at a level of quality that is acceptable. So this would say IHS would have to prioritize basic medical services before paying for new programs. We have talked a lot about the history on this. We know where our problems are. The chairman is trying to move in a direction to help solve some of the problems. I disagree that we are making the major steps. I think we have to totally reform IHS. I have said that to the chairman. He knows the structural problems that are there. I think when we promise health care, we ought to give it. We talked earlier today that one in every four Native American women have a baby without any prenatal care. The average number of visits for those who have prenatal care is half what the national average is. So just in prenatal care, in pediatrics, and diabetes we know we are behind the curve. Yet we are going to add new services in the bill that are already available in other ways. We also know, as the chairman has said, that we spend half per capita on Native Americans than we do on prisoners. We spend less than half than we do on veterans. We spend a third based on what we spend on Medicare. So we are obviously not there, and a lot of it is money. There is no question about it. But it is not all money. It is structural. Obviously, that is the reason for my opposition to this bill because I think we have an opportunity to go much further to totally change the structure and quality and delivery and to get a lot of the bureaucracy out. I think we also need to add money. We need to do all three. This amendment is designed to make IHS prioritize the money. So even though we authorize these programs--this does not eliminate the authorization--it just says you cannot effectively do it until you have funded adequately what you are already promising Native Americans. What this bill will do, in my estimation, is drain resources available to basic core medical services. It is also going to do something else. Our tribes are getting to be pretty good businessmen. What it is going to do is, it is going to put into individual tribes businesses for these services. So what is going to happen is, these services are going to be part of the tribal organization business complex but not part of the service, and so we are going to transfer funds outside IHS, transfer IHS moneys into tribal organizations with no guarantees that the money that was spent is going to come back into health care. So if we were to do this, what I would rather is these be IHS services only, rather than out for bid to be utilized that may be not at a competitive bid price so we enhance private profitability rather than tribal health care. So there is that other little problem. Again, if we make new promises, at a time when we are not funding the promises we have, we are not helping the Native American population. This amendment is about priorities. It is not saying IHS cannot fund these new programs. It is just saying we need to focus on basic medical services first, such as prenatal care. When one in four Native Americans do not have prenatal care, and we are going to add long-term home health care, hospice, DME, and some of these other areas, when we are not taking care of the women who walk in and deliver without prenatal care, it does not make sense. So I will put this amendment up. I am going to ask for the yeas and nays on amendment 4036. I appreciate the consideration of the chairman and his heart toward Native Americans. But a half promise fulfilled is a promise not kept, and that is where we are on health care. Making us prioritize--in some places we will be able to do this; where we have effective, efficient care, they will have the money to offer these services. In areas where we are not doing well, they should not be expanding into new services when they are not taking care of the services we have today. So the flexibility is completely up to the IHS. Nothing limits it other than you have to meet the core basic medical needs first before you go into other areas. With that, I yield the floor and await the response from my chairman. Then I will talk about the other amendment in a moment.

Mr. COBURN. Let me start by saying, improving the health care of Indians in this country is a widely supported goal. Senator Dorgan's heart is in the right place on this issue. He knows the problems we have, and he spent countless hours trying to get to this point with this bill. I do not want to be seen--I have told him, and I committed to him my goal is not to block his progress on this bill. However, I believe this legislation as drafted does not fix the underlying problems. He and I have had several conversations about that. It does not fix rationing that is going on today. It does not fix waiting lines that are going on today. It does not fix the inferior quality that is being applied to a lot of Native Americans and Alaskans in this country. It does not fix any of those problems. In fact, it authorizes more services without making sure the money is there to follow it. The average Native American in this country has $2,100 per year spent on them. Now, let's put that in perspective. The average veteran we take care of has $4,300. The average individual per person, per capita, expenditure in our country is $7,000. Yet we are going to pass a bill that does not fix anything. It does not fix the real problems about addressing the No. 1 problem which is, we are not sending enough dollars to meet the treaty obligations that we have with Native Americans. So really what this bill is, it is called the Indian Health Care Improvement Act, but it improves our position with tribes because we have done something, but it does not improve health care. It is not going to improve health care. It is going to increase the availability of services without the money, without the control, without the quality, without eliminating the waiting lines. As a matter of fact, it is going to add to the waiting lines as I read this bill, as somebody who is somewhat experienced in medicine. Those who say a failure to reauthorize the Indian Health Care Improvement Act is a violation of our trust obligations are correct. However, I believe simply reauthorizing this system with minor modifications is an even greater violation of that commitment. It is a greater violation. Dozens of tribal leaders are not expressing enthusiasm for the current structure. Chuck Grim, an Oklahoman, head of this service, knows what is broken. I have had lots of conversations with him. We know what is broken, we know how to fix it, but we have to be bold in how we go about fixing it. We are not bold in this. We are not changing it. We are not doing the structural changes that have to happen for us to live up to the commitment that we have made to Native Americans. The myriad of problems facing Indian health care in Indian country are many of the same issues that are facing health care delivery throughout rural America. They are compounded, however, in this system by a system that refuses to recognize its own role in holding back health care delivery for Native Americans. In designing health care reforms, markets work when they are allowed to. They lower the price of all goods and services, and they attract much needed outside investment. Many tribes in Oklahoma are at the forefront of new and innovative health care delivery systems. They are poised to become a model for delivery throughout the system. Congress must ensure, however, that their efforts are not discouraged or stopped altogether by the current system. Furthermore, there is no good reason that forward-thinking tribal governments should not be prevented from developing market-driven health care centers of excellence that will attract researchers, physicians, and patients for cutting edge lifesaving treatments. We do not do that in this bill. Furthermore, this legislation fails to focus on empowering individual tribal members. Individual patients tend to receive better care and more effective care when they are empowered to make their own health care decisions. Congress should explore ways to accomplish this objective and give tribal citizens a reason to invest in their own health. Long lines, bureaucratic headaches, and rationed substandard care completely disallow this sort of investment. That is what we have. Our Chairman has been on the Senate floor multiple times showing how we are rationing care, how we have lines, how we do not give quality care, how we take contract health care--it runs out in 4 or 5 months. And so what happens? People who need care do not get it, and we have not fixed that in this bill. Yet we are calling this health care improvement. The health care status of tribal members ranks below the general population. The Federal Government has been providing health care to tribal members for 175 years. The first time was to give them a smallpox vaccine in 1807. That is when we started Indian health care. And what we are doing today in comparison to what our treaty obligations are--in comparison, it is the same thing we are doing to the veterans when we tell the veterans: We are going to give you health care and do not give it. It is the same thing we tell schools: We are going to have an IDEA program and then not fund it. It is morally bankrupt legislation that does not meet the commitments that we say we have. The Snyder Act of 1921 provided a broad and permanent authorization for Federal Indian programs, including--and this is an important thing--the conservation of health; in other words, the prevention of disease, which Chuck Grim was just starting to get into, but we do not have the funding to do it the way we need to do it. We know the manifestation of diabetes and addiction and hypertension and heart disease among our tribal members is higher than any other group in our country. Yet the conservation of health has not been exploited, the paradigm shift that has to happen in Native American care to where we go to prevention instead of treatment of disease. It is not in here. We are not doing it. Last year, we spent $3.18 billion doing this. If we just funded it at the level we fund per capita veterans care, we should be funding $6.5 billion in Native American health care. That is just on a per capita basis, let alone any structural changes on how we might make preventative care, quality care, timely care, and compassionate care a part of Native American care. But we are not doing that. Indians in comparison with the general population are 6.5 times more likely to die from alcoholism. That is a disease we need to be preventing. That is a health care problem. They are six times more likely to die from tuberculosis, a preventable disease; three times more likely to die from diabetes, a controllable and now preventable disease, it is a preventable disease; 2.5 times more likely to die from an accident. Now, how can we look those statistics in the face and say we have met our treaty obligations? We have failed. We have absolutely failed. Only 71 percent of Native Americans receive prenatal care. That means one out of four Native American moms who get pregnant do not have any prenatal care. We ought to be ashamed. We have failed. We have failed. Eighteen percent of Native Americans who are pregnant smoke. That is twice the rate of others. Where is our prevention? Where is our education? Where is the priority on what we can do something about? American Indians suffer from a great death rate from chronic liver disease and cirrhosis. It is 22.7 per 100,000. That is twice what it is for Whites and three times what it is for African Americans in this country. We know what causes it. We do not put the dollars there. We have not put in a streamlined prevention program. My words are harsh. They are not intended for either the chairman or the ranking member. I passionately care that we meet our commitments, and so I do not want you to take the words I say as directed toward you because I know you care as well. Where we have a difference is in the ``now.'' What do we do now rather than what do we do later? I think we should be doing it all now. I think we should radically change how we approach our obligations in Native American health care in this country. Rationing plagues Indian Health Services. It is rationed care. That is why it is not good care. That is why it is not consistent care. That is why it is not preventative care, because we don't have the resources. We haven't applied the resources to the need. Senator Dorgan has had numerous hearings. He has spoken on the floor about this rationing crisis. But if we don't radically change the system, if we don't change incentives in the system, improving the old will just bring more failure. The job vacancy rate for dentists is 32 percent. They don't have 80 percent of the nurses they need. They don't have 85 percent of the optometrists, and they only have 86 percent of the doctors, based on the present system. I am proposing a better system with better care based on prevention, a paradigm that says it is a whole lot cheaper to prevent your illness than it is to treat it once you get it. It is common to hear in Indian Country--and I have heard the chairman say it--``don't get sick after June. Contract money is gone. If you get sick after June, nothing will happen. You will not get the referral to the center to take care of you because we don't have the money. A quote from Dr. Charles Grim, who has been a stellar leader for the IHS: We're only able to provide a certain level of dental services in certain populations. We're only able to refer a certain level or number or types of referrals with our contract health service budget into the private sector. . . . But I guess one generalized statement would be that we have a defined population and a defined budget. . . . But it has led to rationing in some parts of our health care system. Here is the former head of IHS admitting we are rationing the care. When we ration care, we don't match up need with resources. We say: Here are all the resources there are regardless of what the need is. We don't get on the leading edge on prevention. We don't get on the leading edge on treatment because we are scrambling to keep the doors open. How can we have a coherent, fair health care system when we are rationing because the demand is so far greater than we are willing to supply the resources? According to a GAO report in 2005, health care services are not always available to Native Americans. There are wait times and insufficient care. GAO visited 13 IHS-funded facilities in 2005 and found waiting times at four range from 3 to 6 months to get in to see anybody. Six months? That is worse than England. What happens when you can't get in? The disease gets worse. The complications are worse. The quality of the your health gets worse. Also, the cost to meet the need explodes. So what we have done is raised the cost of care. But more importantly, we have failed on our commitment to provide health to Native Americans. Three IHS facilities had 90-mile one-way visits to get into a clinic, many without transportation available to them. Three of these, the average was 90 miles to get to a clinic. Even if they have the resources and there is no access because there is a distance to travel, we are going to see the same problem. Nobody is going to go until they absolutely have to. So we lose the benefit of prevention. Most of the facilities in this GAO report did not have the staff or equipment to offer services onsite so they resorted to contract care. The contract care budget, of course, is small. So what happens? We ration contract care at 12 of the 13 facilities. This idea of rationing isn't a political statement; it is a reality. We are not doing what we are committed by treaty to do. Now we are going to bring a bill to the floor that doesn't meet that commitment. We are still not going to meet the commitment. We will improve it, but we need to overhaul it. We need a top-down, complete change in how we approach our commitment to Native Americans as far as health care. If we did that, we could offer a whole lot more care for a whole lot less money. We have a bureaucracy that is stumbling all over itself. We are spending money. I will get to the point on the number of bureaucratic positions in IHS that don't deliver any care. Gaps in services result in diagnoses and treatment delays which, of course, make the health of the patient worse and raise the cost. IHS reports that their facilities are required to pay for all priority one services but admit that many of their facilities' available funds are expended before the end of the fiscal year and the payment isn't made. I experienced that in my own hometown. People come to Hastings Hospital to deliver a baby. Our hospital hasn't been paid on contract care for years. So those in the rest of the community are going to pay for it. The problem is, there is no continuity in care. Prenatal care was provided. Now all of a sudden you don't have a record and you have somebody you have to take care of, let alone that the private hospital that is there isn't going to get paid for the service. Somebody is going to pay for the service, but contract health care isn't. So the fact is, one in four Native Americans in Alaska aren't getting prenatal care. And we know the risk. The average cost for a premature baby is $250,000, let alone the consequence of the problems those kids have. Why in the world would we ever allow that to happen? It is akin to pouring money down the drain because we have not addressed prenatal needs of Native Americans. Twenty-one percent of those who do get care have less than three prenatal visits on average. That is one in four has less than three prenatal visits. That is like not having prenatal care. Yet we count that as if they had prenatal care. What do we think the consequences will be? The antenatal, postnatal, and perinatal consequences to the Native American population are higher. The birth complications are higher because we are not doing the prenatal care. The average recommended prenatal visits by the American College of Obstetrics and Gynecology is 14. We average six with Native Americans. You can't call that care. Under an overburdened system such as this, drastically expanded services to four broad new areas--and this is the problem I have with this bill--will only drain the resources available to the basic core medical services. We are going to expand where we can offer new services. Many of these people are already eligible under Medicaid or Medicaid anyway, but we are going to expand it. What is going to happen is, the tribal government is going to offer the service, and they are going to take the money off the top. They are going to put that into the rest of the tribal funds. So we are actually going to take money out of dollars for health care for tribal members by expanding care and not making sure there are adequate funds. Making new promises, when we don't keep current ones, doesn't help the Native American population. Let's keep the promises we have already made before we expand services and not throw money at it. It sounds good. The tribes like to hear what we are going to do. We are going to add these four services, but we are not funding the services we are supplying now. Why would we add services knowing that? If we do it, we are going to do it on the cheap. But it feels good because they think we are doing something, when, in fact, we are not fixing the problems. It is kind of like taking a loan out on a brandnew car when you can't buy food. It is the same thing. That is what we are doing with these additional services. The majority of the bill is more of the same. I have expressed to the chairman that I think we need to radically overhaul the care of Native Americans. I will have a lot more to say. I do have some complications with other commitments in terms of markup. My staff e-mailed me a moment ago that you have made some substantive changes in the managers' amendment on some of the Medicaid and the tribal issues related to urban Indians. I will get with you and try to discuss that because it may affect some of my amendments. I wasn't aware of that until this morning. I will have an amendment I will talk about now. I don't know that I will when I actually bring it back up. One way to meet our commitment to Native Americans is to give them options. According to CBO, the amendment I will be offering costs no money. It is a zero cost. But what it allows Native Americans is an insurance policy that says you can apply this and go to any Indian Health Service you want to or anywhere else in the country you want to, but you get to choose. The same dollars get spent, but the services will be far superior. There are two results. One, when we do that, it makes the Indian Health Service have to get more competitive. No. 2, and most profoundly, when we do that, we finally live up to our commitment that is embodied in every treaty we have with Native Americans. Here is the real care. It is not rationed. It is not limited to contract funds. You don't have to get in line to wait in line. You don't have to get an appointment to get an appointment. You don't have to travel 90 miles, if you don't want to. You don't have to have your care rationed. And at no cost increase to the Indian Health Service, we can give Native Americans their own health insurance policy which gives them freedom, dignity, and choice. I know that will be controversial. It is not controversial with any Indian I have talked to. It is controversial with tribal leaders because it takes the dominance of tribal leaders away and gives freedom to members of the tribes to whom we have made a commitment for health care. So as we offer that amendment and look at it, I know there will be objections, but it does--most importantly, with the same dollars--allow us to fulfill a commitment we are not fulfilling today. It allows a pregnant Native American to have 14 visits, allows her to have the same care anybody else would have. It allows us to get better outcomes. It allows us to get a patient into an endocrinologist, where they will manage their diabetes so they will not have complications. Kidney failure is twice as high in this population as anybody else. Why? Because diabetes is not managed. How many of you have gone into a dialysis center and watched people sit there for 8 hours a day, chained to a machine to keep them alive, because we didn't keep our commitment by having the dollars there to prevent the complications of diabetes? This gives an equal ranking to a Native American as a Member of Congress. You can have preventative care for your diabetes so you don't end up on dialysis or with an amputation or losing your vision. It offers them hope. It offers honor and integrity because we finally keep our commitments. I wanted to talk about a couple other things and then I will close and come back. I appreciate the chairman giving me this time. As Congress discusses Indian health care over the next several days, America as a country should take note of what a single-payer system means in terms of the quality of care we can expect. America should not go the route of a single-payer system. That is what we are seeing. That is what we have in IHS. It is a single-payer system. The promise sounds alluring, but the reality is inevitably negative. It is negative in terms of prevention. It is negative in terms of care. It is negative in terms of complications. It is negative in terms of innovation. It is negative in terms of the paradigm of prevention. Second, fixing the system for our Native Americans demands more than adding more new programs and services. We need a fundamental overhaul of the system. The Members of federally recognized tribes whom we have a trust obligation to provide health care for deserve better than is in this bill. Actually, I believe Chairman Dorgan believes that too. He believes this is a stepped process. They deserve a choice. They deserve the security to know they can get health care when they need it. They deserve quality. They deserve the health care outcomes the rest of this country enjoys that they presently do not have. Throughout this debate on this bill, you will hear the same statistics on rationing, wait lines from both the Democrats and Republicans. We see it. We know it is there. Some will argue it is a solution that just involves passing this bill that has new programs. Every time we pass an Indian Health Care Improvement Act bill, we cite the same terrible statistics. We pass the bill because we need to do something. But each time we pass the Indian Health Care Improvement Act, Indian health care does not improve. What does that mean? We pass an Indian Health Care Improvement Act, but Indian health care does not improve. Indian health care never improves because we never fix the inefficiency that plagues the IHS. We just reauthorize and add new regulations, new obligations to the same dinosaur. Now, the statistics I was referring to earlier: The Indian Health Service has 14,392 employees, including 2,192 commissioned officers; the latter COs include 8 Assistant Attorneys General, 439 director grade individuals, 601 senior grade individuals. The salaries for the COs total $135 million. The salaries for all other IHS employees is estimated at $655 million. The IHS spent $33.7 million on travel last year. On travel? Think about what $33 million could do in terms of prevention for the complications of diabetes for American Indians and Native Alaskans. The other significant thing is, IHS carried, in 2005--I do not have the number for 2006 or 2007 yet--their obligated balance at the end of the year was $162 million. Just efficiency in how we spend the money could improve health care in Indian Country. I say to the Senator, Mr. Chairman, I appreciate your efforts. I know you are truly committed to trying to make a difference. I believe we need to be bold. I believe we have an obligation to do better. I believe this is short of the mark. So I am going to be voting against this bill. I am going to be offering amendments to try to make it better. I say to the Senator, I know in the long run you and I have a lot of commonality in how we go about trying to solve this problem. I do not think Indian Country can wait for us to come back. I do not think the lady who gets on a dialysis machine today for the first time thinks we can wait. I do not think the lady who pops into the delivery room who has not had any prenatal care thinks we can wait. I do not think the person who ends up with coronary artery disease at 40 years of age, because their diabetes and their cholesterol and their hypertension have not been managed, thinks we can wait. The body will probably think we can wait. But I think we have a moral obligation to meet our commitments, and that means radical change. When you have a cancer, you do not treat it lightly. You go in, you cut it out, you treat it, you follow it, and you aggressively change things so you make an impact in the quality of that person's life. I think we have to do better. I appreciate the efforts of the chairman and ranking member. My hope is we will live up to our obligations. With that, I yield back the floor.

Mr. COBURN. Madam President, amendment No. 4032, which the chairman has graciously allowed me to discuss at this time, which I also would like to call up and have as the pending order of business under the regular order, is real simple. We do this in a lot of other places, but we do not do it in IHS. I ask unanimous consent for that.

Mr. COBURN. I do not have any problem with that.

Mr. COBURN. Mr. President, I ask for the yeas and nays on the amendment.

Mr. COBURN

Mr. COBURN. Madam President, could the Chair explain the unanimous consent order under which we are operating?

Mr. COBURN. Madam President, we have heard a lot in the press, and we have certainly heard a lot from our own Finance Committee, and we have seen what the House passed in terms of the stimulus package. I think, once again, in our hurry to address a problem, we have not asked: Are we fixing the right problem, the problem in connection with the House leadership passing a bill that will spend $150 billion. One of the first questions we ought to ask is, Where is that money coming from, the $150 billion? Nobody can dispute the fact that we are going to borrow that from our grandchildren; we are going to go to the markets and borrow the money to stimulate our economy. Nobody will dispute the fact that there is very little payback into the Treasury, in terms of tax collections, from this stimulus plan. The facts as they are, we had an overheated housing boom. We can deny economic reality, but until we mark the market--the overinflated cost that has extended credit in our country--and recognize that is going to have to be paid for, we are not going to walk out of this slowdown we appear to be facing. The reality is that the model is the Japanese banking industry: When they refused to recognize the losses, what it did was impact their economy for 10 years. So the realities are that there has to be an economic price when we have an economic excess. Our job should be to make that as easy on our economy as we can, thinking about the future of our economy. Now, all the options that have been presented, when scored in the long term, have very little beneficial effect for the economy other than the psychology we are putting through. The reason it is important to discuss alternatives is because there is a way, which is proven in economics, proven in capitalistic societies, in free market societies, where you can generate stimulus and revenue back to the Government so that, in fact, you solve the right problem, the real problem, and you don't bankrupt your children further, which is what we are going to do whether we pass the House bill or the Senate bill. We are going to steal $150 billion or $190 billion from our grandchildren. I think we ought to think twice about that. Do we really, as senior citizens, want to steal $600, to $800, to $1,200 from our grandchildren for us today? Do we want to do that? Is there another way in which we can stimulate our economy without stealing from our kids and ultimately putting the money back in so that our children don't have to pay for this stimulus package? There is. There are a lot of economic theories and experience in this country that prove that. So let's talk some about what we should be doing that we are not. Instead, we are pandering to people, thinking they are going to get $600 or $800, and we don't have any idea other than to think a third of that money might have a stimulus effect, but it will have a negative effect in terms of what our kids have to pay back. One thing we can do is create certainty about economic decisionmaking. We can extend the Bush tax cuts. We can extend them so people will continue to make positive decisions based on a tax rate they know is there rather than one they know is going to go away in 2 years, which will limit their investment. Second, we can lower corporate tax rates. We now have the second highest corporate tax rates in the world. That hasn't been part of any discussion. We know that when we lower corporate tax rates, we see increased investment, which increases the tax revenues for the country, and we also see economic growth. So there is a positive there, but it is not complete. There is a cost associated with that, but at least there is some feedback. But we have not considered that. We have not reduced the capital gains tax rate on corporations--the people who invest great sums of money on the basis of the fact that if there is a capital gain, if we were to lower that, they might invest more or they might recognize the gain they have today, consequently, even generating taxes. We can index capital gains for inflation. That creates a stable investment environment whereby business decisions will invest in capital, create jobs, which create salaries, which create income, which create tax revenue. We can markedly advance--much more so than we have done in this bill--depreciation schedules if we want to have an impact. We could go to full expensing for capital equipment forever. We don't have to stop it now. What that would do is create investment in capital goods in this country, which would create jobs, which would raise wages, which would create incomes, which would create tax revenues for the country. There are other things we can do besides just send money out the door. We can establish a repatriation window for corporate taxes overseas. The best way to not ever have to deal with this again is to have a corporate tax rate equivalent to what is going on in the rest of the world--have one at 25 percent instead of 35 percent so that we, in fact, are competitive worldwide, so that corporations don't refuse to bring income they have earned overseas back to this country because we have an excessive tax on it, so they decide not to do that. Finally, what we can do is make the Small Business Administration work. Seven years ago, the impact of Government regulation on small business was less than $4,000. It is $7,400 per employee. That is the impact of the Federal Government. That is not the taxes you pay, that is the impact of the regulations in terms of the cost impounded onto small business by the Federal Government. I will end with talking about the budget that was just submitted by the administration. We are going to spend probably $150 billion or $190 billion, and we are not going to pay for it. We are not going to reduce any of the wasteful spending, including the inappropriate payments in Medicare, and there is another $40 billion in fraud. Medicaid has $30 billion worth of fraud and another $7 billion in improper payments. Food stamps has $6 billion worth of improper payments, not counting the fraud. There is nothing associated with fixing what is wrong with the Government so that the American people get value from it. We are going to throw money at a problem rather than secure the future for our children and grandchildren. We can do better. We ought to do better. We should not say we are just going to throw money at the problem. Let's make long-term structural changes in the Tax Code that raise the opportunity for our children rather than lower it by putting debt on their shoulders. Let's make the long-term changes and tough choices of eliminating programs that aren't working effectively, or let's refine programs that are wasteful, not efficient, and loaded with fraud. Let's eliminate the wasteful programs that account for $150 billion of money spent each year. Let's get rid of the $30 billion in waste at the Pentagon. Let's get rid of the $3 billion we spend every year maintaining buildings the Pentagon doesn't want. We don't have a way to get rid of them, but we don't have the courage to change the law. There are all kinds of ways to save a couple hundred billion dollars a year, but it means you have to ruffle some feathers. It is time we do that and do the hard work, rather than the easy work. Thank you for the opportunity to speak in terms of what I think is a long-term way to resolve this economic trough we appear to be facing. I am not confident we are going to do it the right way. I think we are going to do it the politically expedient way, which helps people get reelected but doesn't fix the real problem. To me, to my regret, that is a sad misnomer for this body. I yield the floor.

Mr. COBURN. Absolutely.