John Ensign

Mr. ENSIGN

Mr. ENSIGN. Mr. President, the amendment I am offering is an amendment on medical liability reform. I believe meaningful medical liability reform should be included in any overall health care legislation that we do this year. I have a separate bill from this amendment, a complete comprehensive medical liability reform bill, which I introduced earlier, known as S. 45. In an effort to find a compromise, however, I am offering this amendment today. This amendment was originally offered by Senator Edward Kennedy back in 1995. While many Members of the Senate, including myself, were not here in 1995, 21 Members from the other side of the aisle were here at that time, and they supported this amendment. Those Members included: Senator Akaka, Senator Baucus, Senator Bingaman, Senator Boxer, Senator Byrd, Senator Conrad, Senator Dodd, Senator Dorgan, Senator Feingold, Senator Feinstein, Senator Harkin, Senator Inouye, Senator Kerry, Senator Kohl, Senator Lautenberg, Senator Leahy, Senator Levin, Senator Mikulski, Senator Murray, Senator Reid, and Senator Specter. I would hope these Members will today continue to support Senator Kennedy's amendment from 1995. Clearly, the issue of medical liability reform is even more pressing today than it was back in 1995. We, as Americans, spend more money on lawsuits than any other country in the world and more than twice as much as all but one other country. According to a recent nonpartisan study, the direct cost of health care lawsuits is around $30 billion a year. That is the direct cost to our health care system--around $30 billion a year. These costs are multiplied by indirect costs, especially doctors ordering costly tests out of fear of being sued. Estimates of wasted money spent on unneeded tests range from over $100 billion a year annually to $250 billion a year annually. Let me repeat those numbers. The estimates range from $100 billion to $250 billion annually in unnecessary tests conducted by doctors due to fear of lawsuits. In 2006, an article in the New England Journal of Medicine suggested that as much as 40 percent of medical liability lawsuits are without merit. Medical liability insurance premiums are threatening the stability of our Nation's health care system. These rates are forcing many physicians, hospitals, and other health care providers to move out of high-liability States, limit the scope of their practices, and even to close their doors permanently. This crisis is affecting more and more patients and is threatening access to reliable, quality health care services. I have a good friend in southern Nevada who practices obstetrics. In his practice, he specializes in high-risk pregnancies. Because of the medical liability problems we have seen in the past several years, his insurance company limits the number of high-risk pregnancies in which he can assist. So you have one of the best doctors practicing obstetrics who--because of fear of lawsuits by his insurance company-- is limited as to the number of high-risk pregnancies in which he can assist. If you are a woman with a high-risk pregnancy, it would seem to me you would want the best doctors to take care of you. That only makes sense. Because of the medical liability crisis we are facing in this country, however, the best of the best are limited to the number of cases they can handle. Because of unaffordable medical liability insurance premiums, it is now common for obstetricians to not even deliver babies and it is also common for other specialists to no longer provide emergency calls or to provide certain high-risk procedures. Ask yourself this question: What if you were in need of an emergency procedure; what if you were the woman who had a high-risk pregnancy and could not find a specialist to provide you with the care you needed? The medical liability crisis is threatening patient access to reliable quality health care services all over America. Additionally, costly medical liability insurance premiums have forced some emergency departments to shut down temporarily in recent years. In my home State of Nevada, our level I trauma center closed for 10 days in 2002. This closure left every patient within a 10,000 square mile area unserved by a level I trauma center. Unfortunately, Jim Lawson was one of those in need of the trauma unit at that time. Jim lived in Las Vegas, and was just 1 month shy of his 60th birthday. He had recently returned from visiting his daughter in California. When he returned, he was injured in a severe car accident. Jim should have been taken to University Medical Center's level I trauma center, but it was closed. Instead, Jim was taken to another emergency room, where he was to be stabilized and then transferred to Salt Lake City's trauma center. Tragically, Jim never made it that far. He died that day due to cardiac arrest caused by blunt force from physical trauma. Why was Nevada's only level I trauma center closed? Due to a simple fact: the doctors could not afford medical liability premiums, and there were not enough doctors to provide care. Ultimately, the State had to step in and take over the liability to reopen the trauma center. More than 35 percent of neurosurgeons have altered their emergency or trauma call coverage because of the medical liability crisis. This means that patients with head injuries or those who are in need of neurosurgical services must be transferred to other facilities, delaying much needed care. Dr. Alamo of Henderson, NV, brought another example of this problem to my attention. Dr. Alamo was presented with a teenager suffering from myasthenia gravis. She was in a crisis and in need of immediate medical treatment. Because of the medical liability situation, there was no emergency neurologist on call to assist this young woman. Dr. Alamo called several in the area, and none of them wanted to take her case because of the medical liability situation. So Dr. Alamo had the young woman transported to California by helicopter to receive the medical care she needed. Just imagine if that was your daughter or some close friend or relative. How would you feel? These kinds of situations should not happen and should not be forced to happen because of the medical liability crisis we have in America today. Stories such as these are all too common across our country. To address the growing medical liability crisis in my State of Nevada, the State enacted legislation that includes a cap on noneconomic damages and a cap on total damages for trauma care. Several other States have enacted similar reforms. This should not be a Republican or Democratic issue; this is fundamentally a patient issue. Simply put, the current medical liability crisis means patients cannot find access to care when they need it most in many areas. Without Federal legislation, the exodus of providers from the practice of medicine will continue, and patients will find it increasingly difficult to obtain needed care. As we work on a comprehensive healthcare reform bill, one of our primary goals must be to enact meaningful medical liability reform to help ensure patients access to care. As you know, President Obama addressed the entire Congress on health reform in September. During his speech, he said, ``I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs.'' I think that is quite an understatement. Talk to health care providers. It drastically contributes to unnecessary costs, not just maybe contributes. The President went on to say that he has asked Secretary Sebelius to move forward on demonstration projects in individual States to test ways to put patient safety first and let doctors focus on practicing medicine. Let's face reality. There is no doubt that defensive medicine occurs every day and that the costs to the health care system are staggering. As I mentioned earlier, tens if not hundreds of billions of dollars are wasted every year due to the practice of defensive medicine, largely in an attempt to avoid frivolous, junk lawsuits. Just think of how many uninsured patients we could take care of with that money or how much cheaper premiums would be for those who have insurance. We must stop playing games and start doing something real to address this important healthcare issue. Unfortunately, the underlying bill does not meaningfully address medical liability reform--it only contains a toothless sense of the Senate. The Sense of the Senate notes that Congress should consider establishing a State demonstration program to evaluate alternatives to the current civil litigation system. Let's be honest with ourselves. This is just windowdressing. The Sense of the Senate is just fluff. It ignores the substantial progress that many States have already made with medical liability reform. Capping noneconomic damage awards has been highly successful in a number of States, such as Texas and is something that should be part of health care reform. But, if we cannot reach a consensus on this, then we should at least follow Senator Kennedy's example and limit the amount of attorneys' contingency fees as an important first step. Let's do the right thing. Let's enact real medical liability reform. The amendment that I am proposing today would place reasonable limits on attorney's contingency fees in medical malpractice cases. The limit would be 33\1/3\ percent of the first $150,000 of the total amount recovered by the judgment or settlement. There would be a further limit of 25 percent of any amount recovered in excess of the first $150,000 recovered by the judgment or settlement. While helping to reign in the cost of frivolous medical malpractice lawsuits, this amendment also ensures that States' rights are protected. This amendment explicitly allows States that have different fee limitations to keep them in place instead of these caps. This amendment ensures appropriate State flexibility while at the same time helping to improve access to care and reduce health care costs. Let me repeat. Back in 1995 when Senator Edward Kennedy offered this amendment, these 21 Senators, part of the Democratic majority, all voted for the Kennedy amendment. To be clear, my Medical Care Access Protection Act contains more detailed limitations on contingency fees than those contained in the amendment I am proposing today. But in the interest of finding a starting point on medical liability reform, I am willing to start off the debate by enacting Senator Kennedy's limitations first. By the way, the other side is going to say that the trial lawyers need this money to be able to take these cases. Let's face it, the trial lawyers are mostly the ones who get the money out of these cases. We want to make sure that money goes mostly to the patient. So when you see pictures put up by the other side, you will notice that my amendment would actually help those very patients who are in the pictures that those on the other side will put up. Medical liability reform works, and it is already turning the tide against frivolous lawsuits and outrageous jury awards in some States. We have seen it in California, in Texas and in my home State of Nevada, where the number of medical malpractice lawsuits has decreased drastically. It has been a crisis driving doctors out of business for too long. It is time to protect patients across the country and ensure access to quality health care. To illustrate my point, I would like to tell you about the success of medical liability reform in several States. First, take the example of Texas that passed medical liability reform in 2003. To begin with, access to health care has improved, with 18,252 new physicians coming to Texas. The number of high-risk medical specialists in Texas is growing. Since 2003, Texas has added 768 emergency medicine doctors, 481 heart doctors, 218 obstetricians, 212 orthopedic surgeons, and 48 neurosurgeons. These additions are not limited to metro Texas. The ranks of rural obstetricians have grown by 27 percent; 22 rural counties have added an obstetrician and ten counties have added their first OB; 23 rural counties have added at least one emergency medicine physician and 18 counties added their first ER doctor. In addition to improvements in access to health care, charity care has also greatly expanded due to medical liability reform. Today, Texas hospitals are rendering $594 million more in charity care annually than they were just 6 years ago. That is a 24 percent increase in charity care, which is due to liability savings. Liability savings in States across the country have allowed hospitals to: upgrade medical equipment; expand the emergency room; expand outpatient services; staff ER rooms 24/7 with high-risk specialists; improve salaries for nurses; and launch patient safety programs. Without reforms and the attendant savings, these healthy developments would not have been possible. Lawsuit reform has been a magnet for attracting doctors and the funding mechanism to improve access to care and enhance patient safety. Physicians have seen a decrease in their medical liability premiums. Since 2003, physicians in Texas have saved a collective $574 million on their liability premiums. Today, most Texas doctors are paying lower liability premiums than they were in 2001. All major physician liability carriers in Texas have cut their rates since the passage of the reforms, most by double digits. Texas physicians have seen their liability rates cut, on average, 27.6 percent. Eighty-five percent of Texas doctors have seen their rates slashed 30 percent or more. More than 43 percent of Texas doctors have seen their liability premiums reduced in half. Twenty-five rate cuts have occurred since the passage of the 2003 landmark reforms. In my home State of Nevada, limitations on noneconomic damages has helped to stabilize the medical liability climate and allowed the Independent Nevada Doctors Insurance Exchange to keep rates steady in 2008, following a 20 percent decline in 2007. And rates stayed steady after years of increasing dramatically. In Mississippi reform in 2004 created a hard $500,000 limit on non- economic damages. Since that law took effect, the number of medical malpractice lawsuits has fallen nearly 90 percent, which in turn has cut malpractice insurance costs by 30 percent to 45 percent, depending on the county. Ohio and West Virginia have also seen sizable reductions in frivolous lawsuits and as a result less costly medical liability insurance. These examples prove that lawsuit reform can improve access to care, expand the number of doctors and types of care that hospitals are able to offer, and help reduce medical costs. According to a conservative estimate by the Congressional Budget Office, if Congress adopted my full Medical Care Access Protection Act, the deficit would decrease by $54 billion over 10 years. It would also, according to the CBO, save the private sector about the same amount of money. So over $100 billion in savings that now goes to propping up a lot of frivolous lawsuits across the country. By the way, think about it. If you had medical malpractice committed against you, I believe you should have access to the courts. I believe you should be able to sue. I believe you should be able to get just compensation. The problem is now, because our courts are so clogged with all these frivolous lawsuits, it takes years if not up to a decade to be able to get through the court system. For many of these patients who were severely hurt--many of them die before the case is ever settled. That is another reason we need medical liability reform and we need it now. Let me tell you why I believe medical liability reform has been left out of this bill. Actually, I don't want to tell you why. Let me let Howard Dean tell you why. Howard Dean, obviously, is the former chairman of the Democratic National Committee. I am going to quote from him. [T]he reason why tort reform is not in the bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on, and that is the plain and simple truth. Now, that's the truth. That is a direct quote from Howard Dean, the former chairman of the Democratic National Committee. I hope as this debate unfolds many of my colleagues on the other side of the aisle will change their minds about enacting serious medical liability reform. I hope that at least these 21 Senators who voted for this amendment before will vote for it again when it comes to a vote tomorrow. This isn't a battle between the right and the left; it is a battle between right and wrong. This amendment is a helpful prescription for patients. I know many on the other side of the aisle would like to cap salaries of people who work in the health insurance industry. I hope these same Members would support this simple amendment to limit trial lawyers' contingency fees in a responsible manner. I urge adoption of the amendment and yield the floor.

Mr. ENSIGN. Madam President, there is an urban myth that people like to talk about when they are discussing health care reform. It is like one of those rumors that runs rampant on the Internet. Nobody knows where it started, but you are sure it must be true. The story is about Canadian health care: everyone there is covered, and they have a progressive health care system that we should somehow copy. Well, it is time to bust this myth and tell the American people what a government-run health care system like Canada's would mean for us in the United States. Canada and Great Britain offer what is typically referred to as universal coverage. Universal coverage, however, does not mean unlimited access to care or readily available care. Let me tell you why. Let's talk about spending first. The U.S. spends about 16 percent of its gross domestic product on health care, while Canada spends about 10 percent. I know some Members of this body have been asking: If Canada can spend less money on health care, why can't we? Well, there is a right way to reduce spending with technology, healthier behaviors, common sense, medical liability reform, other things I have talked about; and there is a wrong way. In Canada, the government spends 10 percent on health care by setting a global budget. When the demand for health care exceeds that amount, the Canadian Government does not increase funding. Instead, medical care is often delayed and/or denied. Some estimate that about 750,000 Canadians are currently on a waiting list for medical procedures or referrals to specialists. Madam President, can you imagine waiting up to 6 months for a hip replacement or up to 6 months for cardiac bypass surgery? What if you had to wait up to 4 months to get an MRI. People who live in countries that have government-forced health care systems often wait, and then wait some more, for medical care. This chart shows typical patient wait times in Canada. The blue bar shows median clinically reasonable wait times. The red bar shows actual wait times. So this, in the blue, is what a reasonable patient wait time should be and what is shown in red is what patients actually experience. If you look at this chart and study the wait times, you can see that in every single one of these cases whether it is general surgery, gynecology, internal medicine, neurosurgery, or ophthalmology, the actual wait times are always much longer than what a clinically reasonable wait time should be in Canada. For example, the median clinically reasonable wait time for neurosurgery is 5.8 weeks. But, as we see from this chart, the actual wait time is 31.7 weeks. That is for neurosurgery. That is shown on this part of the chart. Can you imagine having to wait that long for neurosurgery? For orthopedic surgery, the clinically reasonable wait time is 11 weeks. The median actual wait time is 36.7 weeks. This is hard to fathom. In Canada, the wait time depends on many factors. Getting in to see a doctor depends on the province in which you live, whether you are an urban or rural resident, the urgency of your medical condition, and your age. I want to encourage all Americans not to take my word for it on these wait times. You can go to this Web site, http://ontariowaittimes.com, and it will actually tell you what the wait times are for various procedures. As a matter of fact, my assistant who is on the Senate floor with me today broke her arm several months ago. Interestingly, she went to this Web site to find out how long her wait time would be for surgery in Ontario. By the time she would have got in to see a doctor in Canada to have the necessary procedure conducted, her arm would have already healed. It would have healed incorrectly, but it would have already healed. That is unacceptable, but that is typical of what happens in countries where there is government rationing, and where the government sets a global budget. Think about how frustrated you would be if you had to wait that length of time. Some Canadians get tired of this waiting. They leave the queue and catch planes, trains, and automobiles to the United States to get medical care when they need it most. The Mayo Clinic, for example, sees about 2,000 Canadian patients each year. The Henry Ford Clinic in Michigan saw 191 hospital patients from Canada and had about 1,400 outpatient visits from Canada last year alone. Those numbers have increased steadily over the past 3 years. In fact, revenue from Canadian patients has increased by $7.5 million at the Henry Ford Clinic in the last 3 years. Although these major medical clinics do not track why some Canadian patients come to the United States for medical care, I believe the significant wait times in Canada are one of the primary reasons they choose to cross the border. I also believe that Canadian patients come to the United States to reap the benefit of America's research and development and to access new breakthroughs in medical technologies. Many of my colleagues have heard the story of Shona Holmes. Shona, a Canadian citizen, was experiencing numerous conditions, including headaches, fatigue, and severe vision problems. Her primary care doctor in Canada ordered an MRI and the results suggested a brain tumor. Shona would have to wait 4 months to see a neurologist or 6 months to see an endocrinologist in Canada. She couldn't wait that long. Since it would be illegal for her to see a doctor outside the government-run health care system in her own country, she traveled 2,000 miles to the Mayo Clinic to Scottsdale, AZ, and paid for the visit herself. Doctors at the Mayo Clinic diagnosed Shona with Rathke's cleft cyst. Shona returned to Canada with her diagnosis and attempted to have surgery under Canada's government-run health care plan. The Canadian Government wasn't able to do the necessary surgery within a 6-month time period. Since Shona's vision was rapidly declining, waiting more than 6 weeks for surgery was completely unacceptable. So her husband got a second job, took out a second mortgage on their home, and borrowed money from family and friends for surgery at the Mayo Clinic. Incidentally, the Mayo Clinic recommended a second surgery to remove her adrenal gland. So Shona went back to Canada and got in line. It took 3 years for her to get her second surgery in Canada--3 years. In written testimony before the House Energy and Commerce Committee, Shona said: If I had relied on my own government-run health care system in Canada, I would not be sitting before you today. At the very best I would be blind and at the very worst I would be dead. Shona isn't the only Canadian citizen who has come to the United States for access to timely medical care. A private company called Timely Medical Alternatives was created in 2003 to help Canadian citizens obtain medical care in the United States. Over the years, the company has sent more than 500 Canadians to the United States for timely medical care. Richard Baker, the founder of Timely Medical Alternatives said: The Canada Health Act is responsible for more pain, more suffering, and more death than any other piece of domestic legislation in Canadian history. I am concerned that the inclusion of a government-run health plan in the Democrats' health reform bill will destroy the American health care system as we know it today. Section 1323 of this bill establishes the community health insurance option. Don't let the name fool you; it is a government-run plan. States can opt out of the government-run plan if they enact a law prohibiting the offering of the government-run plan in the exchange, but I honestly expect that few States will take this course of action. Regardless of the language indicating that people won't be forced to participate in a public health insurance program and won't be penalized for not participating, I still believe that some individuals will be forced into this government-run plan. I also believe this is just the first step toward a complete government-run plan. Under the bill, the Secretary of Health and Human Services will be required to negotiate provider reimbursement rates. The government typically doesn't negotiate with doctors and hospitals. The government would likely resort to price-setting based on Medicare or Medicaid or use existing government programs as leverage for negotiations, creating similar effects. Remember, Medicare and Medicaid currently reimburse at much lower rates than the private sector. Madam President, I ask for an additional 3 minutes.

Mr. ENSIGN. Madam President, Democrats claim that they will not be putting private health insurance companies out of business, but it seems to me that they are doing everything possible to make it harder for these companies to stay in business. I also question whether Members of Congress will be required to participate in this government- run program. We should be required to do so. If we decide that a government-run plan is good enough for the American people, then I believe that Members of Congress should subject themselves to the same type of care. I know there will be an amendment to do just that. I want to tell a story about how federal government officials don't always think that they should be subject to the same type of care as their country's citizens. Belinda Stronach, a former Canadian Member of Parliament, opposed the privatization of Canada's health care system. Well, that was at least until she got sick. She was diagnosed with breast cancer in June 2007. Although she had led the charge against having a private system in Canada, she didn't want to wait in line in Canada to obtain treatment--so what did she do? As a matter of fact, she traveled to the United States for care--on the advice of her doctor. She went to UCLA for surgery and she paid for that treatment out of her own pocket. I have a feeling that she came to the United States because she knew that if she waited for care in Canada, the chances of her having successful treatment would be a lot lower. Madam President, the wait to see a doctor is not the only wait Canadian patients face. Canada and other countries with government-run health care systems are slow to adopt new medical technologies. And, access to the latest medical technologies is limited. As a result, patients often have to rely on old or outdated medical equipment for treatment. Canadians have less access to MRIs, CT scanners, and lithotroptors than patients in other countries belonging to the Organisation of Economic Co-Operation and Development. Lack of access to cutting-edge medical technology has significant consequences. New medical technologies can often provide faster and more efficient identification and treatment of disease. They can offer the patient safer, less invasive and more comfortable treatments and care, as well as offering new treatment options where none previously existed. What is the secret to other countries' keeping costs down? One is refusing to approve or cover new life saving drugs and medical devices. In 2007, the United States had 25.9 MRI machines per million people. Canada had 6.7 MRIs per million people and the United Kingdom had 8.2 per million people. In 2007, the United States had 34.3 CT machines per million people. The same year, Canada had 12.7 machines and the United Kingdom had 7.6 machines per million people. It took France 5 years to approve the endoscopy pill camera and 10 years to approve implantable defibrillators. Japan is well known for refusing to pay for the latest technologies because of budgetary constraints and has yet to approve, for example, prosthetic titanium ribs and imaging masks for head surgery that have been approved in the United States for the past 6 years. In my home State of Nevada, robotics surgery has become an exciting new frontier. Across Nevada, six hospitals are now equipped with the da Vinci Surgical System which allows patients access to cutting-edge minimally, invasive surgery. In all of Canada, the entire country, there are nine such machines. The United States has 968 machines. Wouldn't you prefer a system that thrives on innovation in medical technology? Where you have access to the most cutting-edge technology that can better diagnose and treat you? Even with this clear discrepancy in technology investment, Democrats have argued that the United States spends more money than any other country on health care and gets worse results. The implication is that we should look to other countries for guidance on how to run our own system better. But if we look, for example, at cancer survival rates, we see that the United States gets better results than other countries that have experimented with broader government control of health care. International studies have found Americans have far better access to new cancer drugs than do patients in Europe and the United Kingdom. The United States also has higher rates of cost-effective prevention measures that can detect certain cancers early when they are cheaper, easier, and more effective to treat. As a result of this superior prevention and treatment, the United States has higher cancer survival rates. Madam President, I would like to show another chart. This chart shows the European cancer survival rates for the major cancers in comparison to the United States. The United States data is in gold; the European Union data is in red. This chart shows 5-year survival rates. This part of the chart shows kidney cancer survival rates. We have significantly higher survival rates in the United States for colorectal cancer, breast cancer, cervical cancer, breast cancer, and skin cancer. You name it, across the board we have better survival rates because we don't ration care, we don't delay care, and we have access to better technology in the United States. Madam President, I would like to be a little more specific when it comes to these facts and figures. A study published in The Lancet Oncology found that when comparing 5-year cancer survival rates, the United States had better outcomes than European countries. Among men, nearly two in three American cancer patients survived for at least 5 years, while fewer than half of Europeans did. Among women, 63 percent survived for 5 years in the United States, versus 56 percent in Europe. According to the study, survival rates for breast cancer were 11 percentage points higher in the United States than in Europe. Prostate cancer is even more alarming, with a 99 percent 5-year survival rate in the United States versus 78 percent in Europe. Colorectal cancer rates were 10 percentage points higher in our country than in Europe. And, survival rates for kidney cancer, cervical cancer, and melanoma were higher in the United States than in Europe. Madam President, I think this body should take a look at what it would mean for quality of care and access to medical care in the United States if we were to adopt a government-run health care system. Many of us on this side of the aisle are opposed to government-run health care systems. We don't want these type of survival rates that are common in the European Union. We don't want people from Canada coming here and not having a place to go to obtain medical treatment. As a matter of fact, if the United States ends up going to a government-run healthcare system, where will Americans go for high-quality care when they need it most? All Americans should think about that as this bill is being considered on the floor of the Senate. We should be very careful that reforms to our health system do not lead to reduced preventive care and poor access to lifesaving drugs. These reforms have led to lower rates of survival in places with greater government control over health systems. These reforms have also proven unsustainable in other countries. The British National Health Service trust is issuing a report that says it will face the most severe and sustained financial shortfall in its history after 2011. In fact, the NHS trust is asking staff to work a day for free, take unpaid leave, and carry forward their vacations in order to save money. Germany's new proposal to reform the health care system met with thousands of protesters because it faces a massive budget shortfall due to rising costs. What are they looking at doing? Introduce fees, raise taxes, and do away with private plans to bring people with those plans into the public system. Sound familiar? France, too, has a gaping hole in its health care budget. France is looking at cutting subsidies in order to stop the problem. Japan faces one of the most difficult problems because of its rapidly aging population. It too has budget problems and has to find a way to offset a 5-percent increase in next year's health care budget despite all of its massive price controls on doctor, medical device, and drug prices. Is this the future of U.S. health care? These are not health care systems that we should want to copy. Contrary to the opinion of some, the United States provides among the best care in the world for patients. The World Health Organization identifies the United States as 37th in the world, but these ratings are faulty. The United Nations World Health Organization uses subjective criteria such as ``fairness'' to rate many countries. ``Fairness'' means that any out-of-pocket expense by a patient is regressive and therefore penalizes poor people more. So, in the view of the United Nations, the United States is 54th in terms of their view of fairness. Consequently, according to the WHO ratings, countries like Colombia, Cuba, Micronesia, Mozambique, Saudi Arabia, Samoa, and Uruguay are ``fairer'' and therefore better than the United States. Something is wrong with that rating. In contrast, the United States is No. 1 in responsiveness to patient care according to WHO. So, if you are sick and want the best care, even the United Nations agrees that the United States is the place to be treated. Michael Moore's movie ``SICKO'' advertised how great Cuban health care is, but he apparently did not see the system used by the 11 million ordinary Cubans where patients ``have to bring their own food, soap, sheets'' with them to the hospital. Some of my colleagues ask, if the United States is No. 1 in responsiveness according to WHO, then why is there lower life expectancy compared to other developed countries? Simple. Because the numbers are wrong. Life expectancy in the United States has been rising as it has been in most of the developed world. All of the life expectancy statistics include accidental and even intentional deaths that clearly have no relation to the merit of our health care system. For example, if you remove car accidents and homicides, both of which are higher in the United States for reasons unrelated to the effectiveness of health care, then the actual U.S. life expectancy is higher. Some economists rank the United States near the top of world rankings when that point is factored in. Moreover, the history of exceptionally heavy smoking in the United States and the recent increase in obesity means that diseases and shortened life expectancies related to these factors have little to do with the effectiveness of our health care system. That is why my approach to health care reform includes creating incentives for people to make healthier choices. We need to get to the root of health problems, not chase phantom foreign statistics. Another example is high infant mortality. The United States has a higher level than other countries in part because of the higher number of low weight babies from teenage pregnancies. That social problem is not related to how effective our health care system is. In fact, a low birth weight baby in the United States has a better chance of survival than in Canada, but we have three times the quantity of low weight babies as Canada does. The bottom line is that the United States has the best doctors, nurses, medical and nursing schools, medical research, medicine, hospitals, medical devices, innovative companies, and health care in the world. It is like that because we demand it. Every night on the news for the past month or so, there are stories about the lines for the H1N1 vaccine. The vaccine supply has been slowly trickling out, and Americans are not accustomed to waiting for their care. They are frustrated about these lines and the priority groups that have denied some of them the vaccine. Welcome to government-run health care. What Canada and Great Britain and other countries do with their health care systems is their business. They have determined that they want the government at the center of their health care system. The government decides what treatments patients can have, how long they have to wait, and how much is invested in technology. Here in the United States, that is the last kind of system we need. Instead, we need to move to a patient-centered system. We want to continue to empower patients to make decisions about their own treatment, to be consumers in the process, and to have access to the care they need. The United States is home to some of the greatest medical advancements in the world. Turning away from that system at a time of great medical promise is not the direction we should be heading. For generations, American researchers, scientists, physicians, and patients have worked together to push the envelope on the best tools for diagnosis and treatment. We have invested in finding cures and vaccines for illnesses. We could be on the cusp of cures for cancer, Alzheimer's disease, Parkinson's disease. The list goes on and on. But what happens when we become a one-size-fits-all, government-centered, bureaucracy-run health care system? We become like Canada and Great Britain, where wait times are unacceptable, where care is rationed, where technology and innovation are not a priority, where the doctor- patient relationship is devalued, and where patients have lost their say in their own care. So, it is not surprising that when people in other countries want the best, they come here. Madam President, let's not put Americans in a position where they may have to wait weeks and even months for medical care. Let's not put Americans in a position where they can't access the latest medical technology or the best prescription drugs. And, let's not have government bureaucrats stand in the way of medical care. This is about patients. This is about creating a patient-centered healthcare system. The bill before us is not the answer.

Mr. ENSIGN. I thank the other side for their indulgence and I yield the floor.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, I ask for the yeas and nays.

Mr. ENSIGN. First of all, I think my colleague from Idaho has made some excellent points about, truly there will be cuts that are going to happen in Medicare. And do not just take the politicians' word for these cuts. Listen to the CBO Director. He is the nonpartisan, I repeat, nonpartisan, official scorekeeper. When asked direct questions, by not only the Senator from Idaho but others, he absolutely says the benefits, especially under Medicare Advantage, will be cut. In my home State of Nevada, tens of thousands--I think about 200,000 altogether--of seniors have voluntarily chosen Medicare Advantage over traditional Medicare. The reason? Very simple. There are extra benefits in Medicare Advantage. You hear the Democrats talk about the doughnut hole in Medicare Part D, which is prescription drug coverage. Well, there is not a doughnut hole under most of the Medicare Advantage plans because the private sector, through its efficiency, has been able to fill that doughnut hole. In other words, they get complete coverage of prescription drugs through their Medicare Advantage plans. Also, under Medicare Advantage, they get additional preventive health care services. They also get vision and dental. And depending on the plan, depending on its makeup, there are different types of benefits to attract seniors to certain plans. It is no wonder that about one out of four seniors in America have voluntarily signed up for Medicare Advantage. Nobody forced them into this system. They voluntarily chose this system. If you think about it, seniors do not like change. For most seniors, they like what they have. They do not like to change. For one out of four seniors to have voluntarily changed, there has to be something pretty attractive about Medicare Advantage. There are some real attractive things for seniors in Medicare Advantage plans. That is why when you actually poll seniors regarding Medicare Advantage, the vast majority of them are thrilled with the coverage they have. They do not want to lose benefits. Who would want to voluntarily lose benefits? But with the $120 billion cut in Medicare Advantage the Democratic majority has put in this bill, about half of the benefits in Medicare Advantage plans will be cut. Isn't that correct, I ask my friend, the Senator from the State of Idaho?

Mr. ENSIGN. That is per month?

Mr. ENSIGN. So $140 per month. According to CBO, about half of those benefits would be cut under this plan, isn't that correct?

Mr. ENSIGN. The Senator from Idaho and I serve on the Finance Committee where a large portion of this bill was written. We both heard Democrats on the other side of the aisle complaining about cuts to Medicare Advantage. Yet when I look in this bill, the total dollar figure in cuts to Medicare Advantage is the same as what came out of the Finance Committee; isn't that correct?

Mr. ENSIGN. Let me make a couple other general points about this bill. I think we have pretty well covered the fact that Medicare Advantage is going to take a severe hit. Medicare overall, that includes hospice care, hospital care, nursing home care, home health-- all of them are taking severe cuts. More than likely, those cuts are going to come, if the government doesn't rescue those cuts in the future, from benefits to seniors. If the government decides not to have those cuts in the future, then the deficit is going to go up. You can't have it both ways. You can't have both a deficit-neutral bill and not have the cuts in Medicare. In other words, you are going to either have the cuts in Medicare or you are going to have ballooning deficits into the future. There are several other problems with the bill that I would like to point out. First of all, we know it is over 2,000 pages; there is incredibly complex language in those over 2,074 pages. It places bureaucrats in charge of health care decisions instead of creating a patient-centered health care system that says the doctor-patient relationship is where most of the health care choices should be made. As a matter of fact, according to the National Center for Policy Analysis, in almost 1,700 places in this bill it authorizes the Secretary of Health and Human Services to ``make, create, determine, or define'' things regarding health care policy. Mr. President, 1,697 times, to be exact, the Secretary of Health and Human Services basically makes health care policy--not doctors, not health care providers; bureaucrats in Washington, DC. You mentioned before there were $\1/2\ trillion in new taxes and about $\1/2\ trillion in Medicare cuts. We know this bill will lead to millions of Americans having increased premiums. We have talked a lot about what is wrong with the bill, however, many on this side of the aisle have offered positive solutions. We have talked about allowing small businesses to join together to take advantage of purchasing power that big businesses have. We have talked about allowing people to buy insurance across State lines. Some States have less expensive plans than others. You can buy your auto insurance across State lines. Why shouldn't we be able to buy our health insurance across State lines?

Mr. ENSIGN. I am glad the Senator from Idaho made that point, because the No. 1 problem with health care in the United States is not quality. We have the finest quality system--by almost any measure, the finest quality health care system in the entire world. The problem is that it is too expensive. We should be going after costs. This bill does not do that. This bill actually raises premiums for tens of millions of Americans. That isn't the direction we should be taking health care. Another idea the vast majority of people on this side have supported is medical liability reform. Once again, in the Finance Committee, we asked the question--I, personally, asked the question of the CBO Director: How much money would medical liability reform--the common one I offered and Senator Hatch offered--how much would that save between the government and the private sector? He said: Over $100 billion. Well, that is not chump change; that is a significant amount of money, $100 billion. Add that to buying across State lines, add that to small business health plans, add that to incentivizing healthy behaviors--add that to the elimination of preexisting conditions. I think Republicans and Democrats alike agree, if you have insurance and you have played by the rules and you get a disease, your insurance should not be taken away or denied. We should eliminate preexisting conditions for those that have played by the rules. We shouldn't allow insurance companies to unexplainably increase rates. We should take a step-by-step, incremental approach to health care reform instead of gutting Medicare, as the Senator from Idaho has talked about, to create a new government entitlement program. That is what we are saying on this side of the aisle. However, it seems to be falling on deaf ears on the other side of the aisle.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, I ask unanimous consent that I and my two colleagues be able to engage in a colloquy.

Mr. ENSIGN. Mr. President, I would like to start by talking about the bill in general.

Mr. ENSIGN. Yes.

Mr. ENSIGN. Maybe 40 minutes, somewhere in there.

Mr. ENSIGN. Mr. President, there is a lot of talk about this bill. I wish to make some general comments about it. First, following the comments of my colleague from Illinois, he said there are not $\1/2\ trillion in Medicare cuts. According to the Congressional Budget Office, there are $464 billion to $465 billion in Medicare cuts. So maybe not quite $\1/2\ trillion, but we are certainly getting close. There are, however, $\1/2\ trillion in new taxes in this bill, 84 percent of which will be paid by those making less than $200,000 a year, a direct violation of the campaign pledge made by President Barack Obama, then-Candidate Obama. This bill will result in increased premiums and health care costs for millions of Americans. This is a massive government takeover of our health care system. As a matter of fact, according to the National Center for Policy Analysis, in this 2,074 page bill--there are almost 1,700, 1,697 to be exact--references to the Secretary of Health and Human Services, giving her the authority to create, determine, or define things relating to health care policy in this bill. Basically, we are placing a bureaucrat in charge of health care policy instead of the patient and the doctor making the choices in health care. I believe we cannot just be against this bill. What I do believe in is a step-by-step approach, an incremental approach, some good ideas on which we should be able to come together. I think both sides agree we should eliminate preexisting conditions. Somebody who played by the rules, had insurance, happened to get a disease, they should not be penalized, charged outrageous prices, or have their insurance dropped. I think we can all agree on that. We should be able to agree that if you can buy auto insurance across State lines, you should be able to buy health insurance in the State where it is the cheapest. Individuals should be able to find a State that has a policy that fits them and their family and be able to buy it there. If you can save money and you happen to be uninsured, especially today, it seems to make sense. Let's have that as one of our incremental steps. I also believe this bill covers some of it, but I believe we need to incentivize people to engage in healthier behaviors. Seventy-five percent of all health care costs are caused by people's behaviors. Let me repeat that. Three-quarters of all health care costs are driven by people's poor choices in their behavior. For instance, smoking. On average, it is around $1,400 a year to insure a smoker versus a nonsmoker. For somebody who is obese versus somebody with the proper body weight, it is about the same, $1,400 a year. For somebody who does not control their cholesterol versus somebody on regulating medication, it is several hundred dollars a year. For somebody who does not control their blood pressure versus somebody who does--let's give incentives through lower premiums to encourage people to engage in healthier behaviors. That will save money for the entire health care system and our Country will have healthier people with better quality lives. Currently, big businesses, because of their number of employees, are allowed to take advantage of purchasing power. We ought to allow individuals and small businesses to join together in groups to take advantage of that purchasing power. They are called small business health plans. I believe my colleagues are going to talk about an idea they have, something I talked about for years, the idea of medical liability reform. There are several models out there. They are going to talk about a loser pays model, which other countries have engaged in and they do not have nearly the frivolous lawsuits nor the defensive medicine we practice in this country. How many doctors order unnecessary tests in the United States because of fear of frivolous lawsuits? Talk to any doctor, and they will tell you every one of them orders unnecessary tests simply to protect themselves against the possibility that a jury may say: Gee, why didn't you order this test even though it was not indicated at the time? That accounts for a large amount of medical costs. As a matter of fact, the Congressional Budget Office said $100 billion between the private and public sector would be saved with a good medical liability reform bill. I believe we need a patient-centered health care system, not an insurance company-centered health care system, not what this bill does, a government-centered health care system, where bureaucrats are in control of your health care. We need a patient-centered system. Before us we have the Mikulski amendment. This is more of government- centered health care. There is a report out based on prevention that indicates that mammograms should not be paid for, basically, for women under 50 years of age, from 40 to 50 years of age, and women in the Medicare population age, the report indicates that they do not need annual mammograms. This was based mainly on cost. If you look at it from a cost standpoint, that is probably correct. But think about it. If you are a woman and you get cancer and you could have had a mammogram diagnose it a lot earlier, you sure would rather have had that mammogram rather than have that mammogram denied. The Senator from Maryland has proposed an amendment to try to fix the problem. The problem is, instead of one government entity determining whether somebody is going to get coverage, the amendment turns it over to the Secretary of Health and Human Services. Another government bureaucrat will determine whether something such as a mammogram will be paid for. According to the Associated Press, her amendment does not even mention mammograms. Senator Murkowski and Senator Coburn have come up with an alternative that actually puts the decision of whether to cover preventive services in the hands of experts in the field. Whether it be a mammogram for breast cancer, or an MRI, which most people think is going to be better than a mammogram for diagnosing breast cancer, or whether it is a test for prostate cancer for men. Those kinds of things should be determined by experts in the field, not by government bureaucrats. The various colleges--the American College of Obstetrics and Gynecology, for instance, has come out with certain recommendations, along with the American College of Surgeons. Those are the experts with peer-reviewed science. Those are the individuals who should determine what the recommendations are as to whether we pay for preventive services, not government bureaucrats. Unfortunately, the Mikulski amendment just gives that determination to a government bureaucrat. That is why we should reject the Mikulski amendment, and adopt the amendment offered by the Senator from Alaska, the Murkowski amendment puts the decision making in the hands of the of the experts, where that decision should be made. Let me close with this point. We have seen a lot of comparisons where are people saying that other countries have a better health care system than the United States. Let me give you the example of cancer survival rates. This chart compares the average cancer survival rates in the European Union and the United States, it makes the point as to whether a government bureaucrat is making a health decision or the doctor and the patient are making the health treatment decision. For kidney cancer, the European Union has a 56 percent 5 year survival rate; the United States, 63 percent survival rate after 5 years. On colorectal cancer, about the same difference between the United States and the European Union. Look at breast cancer, 79 percent after 5 years in the European Union; 90 percent in the United States. The most dramatic difference is on prostate cancer, 78 percent survival after 5 years in the European Union; 99 percent survival rate in the United States. These are dramatic differences. Where would you rather get your health care if you had one of these cancers? The United States or Europe? Canada, has even worse results than this. As a matter of fact, Belinda Stronach, a member of the Canadian Parliament, led the charge against a private system side by side with the government-run system in Canada. She did not want the private system. Tragically, a couple years later, she developed breast cancer. Did she stay in Canada to get treatment, where there is a government-run health care system? No. Where did she go? She came to the United States. She was actually treated at UCLA. Why, because we have a superior system of quality in the United States. We have a problem with cost. Some of the incremental steps I talked about will address costs. I wish to turn it over now to my colleagues who are going to talk about medical liability reform. Let's look out for the patient instead of the trial lawyers in the United States. Their idea on a loser pays system, I think, has a lot of merit, and it is something this body should consider very seriously. I yield the floor to the Senator from Georgia, my good friend and colleague.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, these pieces of legislation were put on our desks to show the American people what we are dealing with. We have only just started going through these bills. Already we have found major problems with the legislation. What we are going to talk about over the next few minutes is the premium increases for the American people. If you have insurance now, your premiums are going to go up because of this legislation we have before us. Probably in other ways we don't even know about yet, we will discover in the future, but we at least know some ways that are going to cause the premiums to go up. Let me first talk generally about the bill and what some of the problems are and just briefly on some alternative ideas Republicans have come up with in more of a step-by-step type approach. We know this bill cuts Medicare by $465 billion, including $118 billion in Medicare Advantage cuts. That means millions of seniors who are on Medicare Advantage today will lose the plan they have. Medicare Advantage plans in my State are incredibly popular among senior citizens. I know they are across the country. We know taxes are going to go up by almost $500 billion. We know premiums are going to go up for millions of Americans. This bill was supposed to bend the cost curve. Because it is actually deficit neutral, maybe it helps the deficit a little bit because of the smoke and mirrors they play with it. They say that bends the cost curve, but when we look at the American people and the actual cost they will be paying for health care, their cost curve continues to go up and up and up into the future. This bill will also lead to rationing. We saw this week a Federal board that talked about mammograms, and it caused an outrage in women across America. That is the sort of thing that is going to happen because of this legislation. Federal bureaucrats are going to be in charge of your health care, not your doctor and you. We need to have legislation that focuses on that doctor-patient relationship that should be so sacred in our health care system today. Republicans have come up with the idea of medical liability reform to start driving down the cost of all of this defensive medicine that is practiced. We all know doctors order all kinds of unnecessary tests to prevent themselves from being sued in all these frivolous lawsuits. Both sides agree, let's eliminate the preexisting conditions. That is kind of a given. That is something on which we all agree. That is part of the step-by-step approach this side of the aisle would certainly be willing to do. I also believe we need to encourage healthier behavior in America because 75 percent of all health care costs are because of people's behavioral choices--smoking, people who are overweight. We know obesity contributes to every kind of cancer, to heart disease, diabetes. It is epidemic in this country. Look at our young people. If we don't turn around people's behavior, get them to exercise more, eat right, quit smoking, I don't care what health care reform you pass, we are not going to do anything about driving down the cost. And the high cost of health care is the No. 1 problem with our system. We believe we should have small business health plans where small businesses can join together to buy health insurance, take advantage of purchasing power that larger businesses have. We believe individuals should be able to buy across State lines the way you do with car insurance. If your State is too high on insurance, buy it in another State where it is cheaper, where maybe they don't have as many mandates. Doesn't that make sense? We also believe we should have transparency on cost and quality. When you walk into your doctor's office, you should be able to get a written estimate of what it is going to cost. You should be able to shop that estimate so that we have more consumers making more intelligent choices on health care. When was the last time you went into your doctor's office and got a written estimate or knew how much something was going to cost? I practiced veterinary medicine for many years. When you walk into my practice, you get a written estimate. We have you sign that written estimate because we have to give that. That is part of our general practice. We need to bring that into human medicine, whether it is hospitals or doctors' practices. We need to have transparency for cost and quality. How does this bill drive up premiums for Americans? First, there are nine new taxes put in by the Democratic majority: a 40-percent insurance plan tax for what are called Cadillac plans; another tax on insurance companies; an employer tax; a drug tax; a lab tax; a medical device tax; a failure to buy insurance tax; a cosmetic surgery tax, brand new in this bill; and also an increased employee Medicare tax, a brandnew tax structure on Medicare taxes. Who pays for these kinds of taxes? It isn't just insurance. On the failure to buy insurance, 71 percent of that tax is going to be paid for by people who make less than $120,000 a year. Almost every one of the taxes I just put up of those nine new taxes-- the vast majority of them are paid by people who President Obama, when he was campaigning, said would not pay one dime more in new taxes. He repeated that promise time after time. He said: No new fees, no new taxes, capital gains. He went through the whole litany of types of taxes that would not be raised. Yet in this plan approximately 80 percent of all of the new taxes are paid by people making less than $250,000 a year. Another way this massive piece of legislation raises premiums is this thing known as cost-shifting. The doctor from Wyoming practiced medicine. He was talking about the Mayo Clinic and why the Mayo Clinic, the Cleveland Clinic, and other places and other doctors don't want to take Medicaid and Medicare patients anymore. Why? Because the government pays 20 to 30 percent less than private health insurance in reimbursement to doctors; isn't that correct?

Mr. ENSIGN. How many more people are going to go on the Medicaid rolls?

Mr. ENSIGN. Because you were in the practice of medicine, I ask the Senator from Wyoming, I have heard numbers as high as 15 million new people on Medicaid, plus we have a new public option, so there will be more people on another government plan. What will happen as far as cost shifting to those of us who have private insurance? For those tens of millions of Americans who have private health insurance, what will happen to their cost of insurance when more people are on government plans?

Mr. ENSIGN. If the Senator from South Dakota would yield, I wish to get your comments--maybe from both of my colleagues--on a couple of quotes from the Congressional Budget Office as well as the Joint Committee on Taxation dealing with these premium increases and who is actually going to bear the taxes. Because a lot of people think that: Well, let's tax the insurance companies. Let's tax the medical device companies. Let's tax somebody else. Well, this is what the Congressional Budget Office says. Let me read a couple quotes. One quote is: Although the surcharges would be imposed on the firms, workers in those firms would ultimately bear the burden of those fees, just as they would with pay-or-play requirements. . . . Many of those workers are more likely to have earnings at or near the minimum wage. So it is the low-income people who are going to end up paying when you actually put some of these taxes that we have talked about in. Here is another quote from the Congressional Budget Office. Let's remind folks, the Congressional Budget Office is nonpartisan. It is not Republican, not Democratic. They are kind of the objective scorekeeper around here. They say, these taxes ``would increase costs for the affected firms, which would be passed on to purchasers and would ultimately raise insurance premiums by a corresponding amount.'' The last economic quote is this. This is by the Joint Tax Committee: Generally, we expect the insurer to pass along the cost of the excise tax to consumers by increasing the price of health coverage. I say to the Senator, this is what you are talking about on that other chart you have up. I wish to hear your comments on that.

Mr. ENSIGN. Maybe we could have the Senator from Wyoming comment. One of the big things Republicans have been talking about--instead of driving premiums up, which this bill does--is driving premiums down. Maybe the Senator can discuss medical liability reform, which the Congressional Budget Office, which is a very conservative estimate, has said would save about $100 billion in medical costs in this country. As a practicing physician, maybe the Senator could talk about the unnecessary tests that are ordered, the huge increases in medical liability insurance costs that physicians face today.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, one of the hallmarks of the Democrats' health care bill is that it spends a tremendous amount of money--more than $1 trillion. When the true 10 year costs are reflected, it is actually well over $2 trillion. That is a hefty price tag, and most Americans want to know who is going to pay for this. Contrary to what Democrats want you to believe, this bill will be paid for by all Americans, including low- and middle-income families and small business owners. So for the next week, I want taxpayers as they go about their daily activities to take a moment to understand why they will be paying a new tax for each day of their hardworking week. Monday is not usually a favored day for most folks during the week-- and if this health care reform passes, it will be absolutely a miserable day for families making less than $200,000 a year. That is because 91 percent of you will start the week off by paying a $200 billion tax on health insurance. I have talked about this before at length, this so-called tax on ``Cadillac'' plans. It is actually a 40-percent tax on high-cost premium ``Cadillac'' plans. But the people who are going to pay for these plans and for this tax are more likely driving minivans, used cars, and cars that are paid off. That is because it disproportionately impacts middle-income families. That is new tax No. 1. But there are more. The 40-percent insurance plan tax is what I just talked about. But all told, there are seven new taxes in this health care bill, and maybe more to come. These new taxes, as shown on this chart, fall on some people directly and on others indirectly. The nonpartisan Joint Tax Committee testified that these new taxes--however they are named--will act as excise taxes and will be passed on to consumers to some extent. So, on Tuesday, as your kids are getting ready to get off for school, do not forget that you will be paying higher taxes on insurance premiums because of a new tax on insurance companies. It is the insurance tax. I want to quote a letter the Joint Tax Committee wrote. Remember, this is the nonpartisan Joint Tax Committee. They wrote to me in response to my concern over this debilitating tax. I quote: An insurer offering a family health plan that exceeds the excise tax threshold and is subject to the excise tax faces an increase in the cost of offering that health coverage. Generally, we expect the insurer to pass along the cost of the excise tax to consumers by increasing the price of health coverage. So Tuesday is not a great day either in this new week of taxes. On Wednesday, our small businesses--the engine of our economy--will be taxed if they do not offer health insurance. That is the employer tax, tax No. 3. The employer tax will hit small businesses and make it more expensive to hire workers. I do not think that is a good idea when the Nation is facing an over 10-percent unemployment rate. Those who are hired will see their wages reduced because of the required employer ``responsibility'' payments. That is what they are called. The Congressional Budget Office--which again is a nonpartisan entity--has explicitly stated: Although the surcharges would be imposed on the firms, workers in those firms would ultimately bear the burden of those fees. . . . The tax credit to small businesses does little to help because it only helps firms with 25 employees or less, and it is temporary. Also, this tax credit drops off so suddenly for firms with more than 10 employees that some firms will be penalized--actually penalized--for adding jobs or raising workers' pay--clearly, a perverse incentive. So Wednesday is clearly not a good day for small businesses or their employees, especially those making minimum wage. So I hope you didn't have to call in sick on Thursday, because if you go to a doctor and get a prescription, there is a new tax on the pharmaceutical companies that you will pay. This is tax No. 4, the drug tax. Don't think about using your health savings account or flexible spending account for the over- the-counter medication you need as well. Under the House plan, nonprescription medications can no longer be purchased with moneys from these accounts, and under the Senate plan, there is a $2,500 cap for pretax dollars that can be used in these accounts. The weekend is so near on Friday; but wait, if you need some lab work done, you will have to pay a new tax on clinical laboratories. This is the lab tax. You think your work is over on Saturday, but you will still be paying more taxes under this bill. If you need surgery, there is a new tax on medical devices, such as pacemakers, prosthetics, and hearing aids. This is No. 6. This raises the cost of health care. This is passed on to the consumers. All these taxes have one thing in common: They do raise the cost of health care for middle-income Americans. My Democratic colleagues may claim they are raising taxes on health care companies, not people, and people will be better off once all this tax money is collected in Washington and then used as subsidies. The truth is, the people are paying and many are in the middle class who Democrats claim would be spared. It is true some people may, on a net basis, get more subsidy than they pay in higher taxes, but over 46 million middle-income families will pay more than they receive. In other words, their health care costs in the net are going to go up. They lose under this health care bill and these are middle-income Americans. According to the analysis from the nonpartisan Congressional Budget Office, from which I wish to quote now, these taxes: Would increase costs for the affected firms, which would be passed on to purchasers and would ultimately raise insurance premiums by a corresponding amount. So now it is Sunday, historically a day of rest but not for these new taxes. There is one more tax that again falls squarely on lower and middle-income families, a penalty excise tax for failure to obtain insurance. That is tax No. 7. We are faced with a bill where, according to the Congressional Budget Office, at least seventy-one percent of the individual mandate penalties would fall on the backs of American families making less than $120,000 a year. Remember what the President said: No new taxes on anybody making $250,000 a year or less. Actually, probably over 90 percent of this tax will be paid by those on whom the President said not one dime in new taxes will be raised. Yet under this bill that is coming before the Senate, their taxes are raised and they are raised significantly. Well, we have run out of days of the week, but the Democrats are not finished yet. If you have been using pretax dollars in a flexible spending account, which most Federal employees have and a lot of other people who are employed by other companies have as well, and you pay for services not covered by your plan, such as speech therapy for a child with autism, you are out of luck under this bill. As I said earlier, the Federal spending accounts are capped at $2,500 in this bill, so your income tax will rise as well as your medical expenses. If you have been dealing with extraordinarily high medical expenses and have been counting on qualified medical expenses tax deductions to pay for care or tuition for a special needs school, again, you are out of luck. The itemized deduction bar will be raised from 7.5 percent to 10 percent of your income in this bill. In other words, this bill hurts those who are being hit hardest by medical catastrophes. In committee, my colleagues and I on the Republican side tried to inject some limits to this tax mania. We offered an amendment to carve out lower and middle-income families from paying taxes. I offered an amendment to protect the middle class, specifically, from the onerous penalty excise tax for those who fail to obtain insurance. Unfortunately, on party-line votes, the Democrats voted down those amendments. I offered an amendment to eliminate the growing threat that the 40- percent insurance tax posed to every American with insurance, but, once again, the majority voted it down. We offered amendments to strike some of these specific, heavy-handed new taxes, but, once again, the majority, on party lines, voted them down. We tried to apply limitations so these taxes would not go into effect if they caused consumer costs to rise. The majority, again, voted them down. We tried to prevent these new taxes from hurting veterans, but as Democrats first accepted it, they then passed a second amendment to eliminate the protections. We tried to ensure that vulnerable Americans would not be hit with a tax increase on catastrophic medical costs. Again, the Democrat majority in committee voted it down. After losing every attempt to remove these new, onerous taxes, we tried to preserve the ability of Americans to continue to use their flexible spending accounts. Once again, that was voted down by the majority. There are at least seven brand new taxes in this bill--one, two, three, four, five, six, seven new taxes--with more taxes being discussed. Before the final bill is completed, I am sure there will be more taxes in this bill. The House bill has a surcharge on small businesses. They are also talking about adding a value-added tax, which would be a regressive national sales tax on everyone, and a new windfall profits tax on insurance companies. There is even talk of a tax on soda pop. All these taxes do is cost Americans more money without giving them much in return. Even if the spending in this bill was worthwhile, these sweeping and unreasonable taxes would more than outweigh the benefits. It is very clear America's lower and middle classes will bear the brunt of these new taxes. On top of that, they will not be allowed to keep the insurance plans they have. Instead, they will be forced into a new experimental system that will succeed only in exploding our deficit spending for generations to come. So where is the break for hard-working families, we have to ask. Under this plan, they pay for government-run insurance to cover more Americans. They lose their own insurance--many of them--along the way, and they watch as deficits continue to eclipse their children's futures. That is not even close to the American way. On behalf of millions of American workers, families, and small businesses that sent us to Washington to be their voice, I cannot stand by and watch the majority destroy our chance for meaningful health care reform that does not bankrupt our Nation. I am going to do everything in my power to stop these new taxes from becoming reality. I am confident, with the American people behind us, we can stop these new taxes. We can start over, in a bipartisan way, and go step by step and come up with health insurance reform that controls costs, preserves and even improves quality, and doesn't end up with a government-run health care system that cuts over $500 billion in Medicare and raises $500 billion in new taxes. I urge our colleagues to work together--not as Republicans and Democrats but as Americans--so we can preserve the quality of health care we have enjoyed in this country for so long but do it in a way that is more affordable and provides more access to more Americans. I yield the floor and suggest the absence of a quorum.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, my amendment is very simple. It would add $172 million to the State Criminal Alien Assistance Program. This program provides payment to States that incur correctional officer salary costs for incarcerating undocumented criminal aliens for at least one felony or two misdemeanor convictions. This amendment is offset by simply an across-the-board decrease in spending, so it is budget neutral. I believe this is an important amendment. It is especially important if you are in one of the Southwestern States or border States. Local law enforcement in those states incur a lot of expenses; those associated with illegal immigrants, especially those who are criminals. I urge my colleagues to support this amendment and match what the House of Representatives did when they passed this amendment by a vote of 405 to 1. Let's go along with the House of Representatives and make sure our local law enforcement has the resources they need to fight those who are here illegally and committing serious crimes.

Mr. ENSIGN. To clear up a couple of facts, first of all, not every State has the same problem with illegal immigrants that other States do.

Mr. ENSIGN. I move to waive the applicable sections of the Budget Act with respect to my amendment and ask for the yeas and nays.