Tom Harkin

Mr. HARKIN

Mr. HARKIN. The Senator is correct. The managers' amendment creates a clear bright line exemption for individuals described in 1402(g). This religious conscience exemption applies whether one is unemployed, a self-employed Amish person, an Amish person working for an Amish employer, or an Amish person working for a non-Amish employer.

Mr. HARKIN

Mr. HARKIN. Mr. President, for the last several weeks, all we have heard from the other side is attack, attack, attack. All we have heard from the other side is no, no, no. They keep talking. I just heard the Senator from Arizona saying this is not a bipartisan bill. I have heard so much talk on the other side in the last several weeks about how this should be bipartisan. Well, let's look at that for a second. As I see it, the Republicans have no bill of their own. Our bill has 60 Democrats, a supermajority, a supermajority. Well, I guess there is a bill over there. It is the Coburn-Burr bill. It has seven cosponsors. That is it. That is it. Nothing else. Not all the Republicans are supporting it. My friends on the other side are all over the place. They can't even agree among themselves what they want to do. They have no comprehensive bill as we have come up with. So I keep hearing that we Democrats are not bipartisan, but whom do we deal with? Just the Senator from Arizona? Just the Senator from Tennessee? How about the Senator from Oklahoma or the Senator from South Carolina? So I am sorry. I feel sorry the Republicans are all split up. They have not done their own homework to pull their own Senators together for something positive. So what they have done is they pulled together to say no, to try to kill the reform bill we have worked so hard on all year. We extended a hand. If we had wanted to ace out the Republicans, we would have followed their lead on what they did in 2001, when they rammed through that tax cut for the wealthy. They did it on reconciliation so we couldn't filibuster it, so we couldn't have any debate on it. That is what they did. We didn't do it that way. President Obama said we want to hold out the olive branch. We want to work with Republicans, so that is what we tried to do. Under the leadership of Senator Dodd on our committee, we had numerous meetings with Republicans. We had a markup session that lasted 13 days 54 hours. We accepted 161 of their amendments and, in the end, everyone on the Republican side voted against it. Senator Baucus bent over backward, week after week. He not only went the extra mile, he went the extra 100 miles to try to get Republicans to work with him on this bill. In the end, only one Republican would vote for the bill out of committee. So that is what we have. I am sorry to say my friends on the other side are in total disarray. They have nothing they can agree on. Well, we have something we have agreed on. Sixty, a supermajority, have agreed on moving a bill forward, a pivotal point in our history, in a decades-long march toward comprehensive health reform. It has alluded Congresses and Presidents going back to Theodore Roosevelt. My friends on the other side defend the status quo. They want us to vote our fears--fear, fear, fear. Everything you hear, it seems, on the other side is fear. Be afraid. Well, it is not going to work this time because what the American people want is not fear, they want hope. They want the hope they will have the health care they need when they have to have it at a price that is affordable. They want to have the peace of mind and security of knowing that their children, if they have a preexisting condition, will be covered by health insurance. They want to have the peace of mind of knowing that if they lose a job, they don't lose their health insurance. The American people want the hope and the security of knowing that if they get ill, they will not be dropped by their insurance company. They want the hope and the security to know they aren't just one illness away from bankruptcy. We are the only country in the world--the only one--where people can go bankrupt because they owe a medical bill. No other country would allow that to happen. We are the only one. This bill is going to stop that. People will not have to fear going bankrupt because someone in their family got a chronic illness or a disease that is going to cost a lot of money. The American people want us to move forward, and we are going to do it tonight at 1 o'clock. We are going to move forward. We are not going to vote fears, we are going to vote hope. We are going to tell the American people we are going to do three big things. First of all, we are going to cover 94 percent of Americans with health insurance--94 percent. Thirty-one million people out there without health insurance are going to get health insurance. Secondly, we are going to crack down on the abuses of the insurance companies. No more cancelling your policy just because you got sick. No more lifetime caps which basically cause more and more people to go into bankruptcy. No more of those lifetime caps. We are going to make sure your kids can stay on your policy until they are age 26. We are going to do away with all these preexisting condition clauses next year for children, up to age 18, and then for everyone later on after we get the exchanges set up. Insurance companies will not be able to rescind your policy or drop you because you got cancer or heart disease. If you are a person out there who has your own health insurance policy right now and you like it, you can keep it. But guess what this bill will do. It will lower your premiums, and it will improve your coverage if you want to keep your own health insurance that you have right now. Every year, about 45,000 Americans die in this country because they have no health insurance. Johns Hopkins did a study and said that children who have no health insurance are 60 percent more likely to die because of hospitalizations than kids who have health insurance coverage. It is a moral disgrace. The health insurance policies of America, what we have right now is a moral disgrace. You can talk to people from other countries, our closest allies, our closest friends who share so many of our values, and when they find out about our health care system, they say: How can you put up with it? This is disgraceful. You are the leader of the free world. You are supposed to set the example. And what a terrible example we have set in health care, what a terrible example. Well, we have finally arrived at one of the most significant moments in the history of the Senate, one of the most significant. Our former chairman, Senator Ted Kennedy, fought all his life for national health insurance, and years ago, back in the 1960s, said health care ought to be a right, not a privilege. He said that over 40 years ago, almost 50 years ago, that health care should be a right and not a privilege. It was always his highest priority. It was his great dream of an America where quality, affordable health care is that right. He thought of it as a moral imperative--a moral imperative. A lot of times, we lose that. We hear a lot of debate about how much this is, who is going to lose this, all these scare tactics. We see all these numbers and all that kind of stuff. We forget the essence of it. It is a moral imperative. We are called upon to right a great injustice, a great wrong that has been put upon the American people for far too long. It is a moral imperative that confronts us now that we will vote on in half an hour. We are closer than we have ever been to making Ted Kennedy's dream a reality. A lot of people have worked very hard on this bill. I mentioned Senator Baucus. I mentioned Senator Dodd; Senator Reid, our leader, the amount of hours he has spent and the days he has spent here without his family, without going home, being here all the time working; our assistant leader, Senator Durbin. So many people have worked so hard on this bill. We have had so much input. Everyone has had input on this bill. Our Republican friends have had input on this bill. They had it in our committee. As I said, we accepted 161 amendments. So I guess you can say this bill has a lot of authors. But there is really only one author of this bill--Senator Ted Kennedy. It is his bill because it does get us the start. To my friends, I say this is not the end of health care reform, it is the beginning. But we must make this beginning in order to fulfill that dream and really make health care a right, not a privilege. In half an hour, let's make history. The other side says fear. We say hope. The other side says no. We say yes. We say yes to progress, yes to people, yes to health care as an inalienable right of every American citizen. I yield the floor.

Mr. HARKIN

Mr. HARKIN. Mr. President, I guess I can say we crossed the Rubicon last night at 1 o'clock. Reading some of the press reports, of course, most of the news didn't have it because it occurred at 1 a.m. Some of the different reports have been online this morning. It occurred to me that a lot of people are missing the overall importance of what happened last night. We can get into the fine tuning and the nitpicking and sort of the fear and the anger I hear from the other side. Every time I listen to speeches over there, with the exception of the last speaker, almost all the speeches I hear from the other side, it is fear, be afraid, be afraid. It is some built-up anger over there. I think what happened last night is, we crossed a demarcation line, the demarcation line of which on one side health care is a privilege. We have been on that side of the line for a long time. On the other side of that line, health care is a right. We stepped across that line last night. We are now in the process of saying health care is a right, an inalienable right of every American citizen. Is that what so upsets my friends on the Republican side? I don't know. Something is upsetting them. Because this is a momentous change we are doing. I keep hearing from Republicans they want us to deal in a bipartisan way. We tried all this year, both in the HELP Committee and in the Finance Committee. Senator Baucus bent over backward to accommodate. But at every turn, Republicans said no, no, no, no, no--all year long. How can you be bipartisan when the other side has nothing to offer? There is no bill on the Republican side. There is a bill. It has about nine cosponsors--Senator Coburn, Senator Burr, maybe seven others, but not every Republican is on that. I hear bits and pieces of this and that every time I hear these speeches. Most of it is attacking what we have done. I hear nothing positive from their side. It is very hard to deal with a party that is in total disarray as the Republicans are. If they had a bill they were supporting and that was supported by all of them, such as the bill we have here which is supported by 60 Democrats, I think then you could find some reason for meeting and working things out. But since there is no one on that side who has a comprehensive proposal, it is hard to do that. We have had to kind of plow ahead as best we can. We have not done this alone. In our committee, we met for 13 days. We had 54 hours of markup. No amendment was denied. Republicans offered over 200 amendments. We adopted 161 of them. That is pretty good. Yet in the end, every Republican voted against it. So it is not as if we didn't try and we didn't hold out an olive branch to work with people to get a bill that was truly bipartisan. We did in our committees, both the Finance and HELP Committees. Now it has come down to fear and anger on the other side and some nitpicking. My friend from Iowa--and he is truly my friend--was talking about some provisions put in the bill for special reasons and so forth. I admit fully and openly that I was part of that. Did I put something in the bill that was sort of particular to my State of Iowa? Yes, I did. But it doesn't just affect Iowa. There are several States in which we have hospitals that are not as big as the big hospitals with the volume. They are not so small that they are low-volume hospitals that get help. They are kind of in between. They call them tweener hospitals. We have eight of them in Iowa: at Grinnell, Keokuck, Spencer Municipal, in Carroll, St. Anthony Regional; Muscatine; Fort Madison; and Lake Regional Hospital at Spirit Lake. There are a number of these in the United States. I forget the total number; not a large number, they just fall in a place where they are too small for the big and too big for the small. As a result, they have been getting a bad deal from Medicare reimbursement. There is a fix in this bill that will allow them to get adequate reimbursement. I don't see anything wrong with that. It is fixing a specific problem that the bureaucracy can't seem to quite get fixed. That is in the bill. I make no bones about having put that in there. I think it is a good deal. It is something that is going to help a lot of hospitals, not only in Iowa but a few other States. One of the things I wish to talk about today is something I have been on for many years, and that is the huge amount in this bill on prevention and wellness. It has not been written about a lot. People have been focused on the public option and the abortion issue and a few other items such as that. Perhaps one of the most profound parts of this bill and the one I believe will do more to bend the cost curve, as they say, than any other single thing is the provisions dealing with prevention and wellness. In the past I have said many times that we don't have a health care system in America. We have a sick care system. When you think about it, if you get sick, you get care. But precious little is spent out there to keep one healthy in the first place. So people get sick. You go to the doctor, the hospital. We patch and fix and mend and try to make them well. Your mother was right, you know: Prevention is worth a pound of cure. We have fallen far short of that in this country. There is a remarkable array of provisions in this bill that promote wellness, disease prevention, and public health. Together they will move us from a sick care society into a genuine wellness society, into a true health care system, not just sick care. What better way to reform our health care system than to restrain health care costs by helping Americans to prevent chronic diseases, stay healthy and out of the hospital in the first place. Right now, as we have heard so many times, we spend more than $2 trillion each year on sick care. But 4 cents of every dollar is invested in prevention and public health. I submit this is a major reason why Americans spend twice as much per capita on health care as European countries, but we are twice as sick with chronic disease. We spend twice as much as Europe on health care, but we are twice as sick with chronic diseases. The good news is that by ramping up the emphasis on wellness and prevention, we have tremendous opportunities to both improve the health of the American people and to restrain health care spending. That is the aim of this bill which makes significant new investments in prevention. For example, our bill would ensure that seniors have access to free annual wellness visits and personalized prevention plans under Medicare. We have never had that. For the first time seniors will have access to free annual wellness visits and personalized prevention plans under Medicare. That is a big deal. So many seniors today, if they get sick, go to the doctor and get more pills. Now they will be able to go in, have their annualized checkup, see what is wrong, and have a personalized prevention plan for each person under Medicare. It will also encourage States to improve coverage and access to recommended preventative services and immunizations under Medicaid. At a minimum, States will provide Medicaid coverage for comprehensive tobacco cessation services for pregnant women. That is just the start. Right away, at a minimum, they have to do that. In addition, the bill requires insurance companies to cover recommended preventive services with no copayments or deductibles. This is critical because we know that all too often people forgo their yearly checkups or essential screenings because either their insurance companies don't cover them or because they have high copays and deductibles. Another critical element in the bill essential to a sustainable push for wellness is the creation of a prevention and public health trust fund. Typically prevention and public health initiatives are subject to unpredictable and unstable funding. This means that important interventions, things such as education about nutrition and assistance for smokers who want to quit, often go unfunded from one year to the next. They get funded a little bit one year or cut the next; funded a little bit the next year, cut the next. The prevention and public health fund in this bill will provide an expanded and sustained national investment in programs that promote physical activity, improve nutrition, and reduce tobacco use. We all appreciate that checkups and immunizations and other clinical services are important. But this bill also recognizes that where Americans live and work and go to school also has a profound impact on our health. That is why a number of provisions in the bill focus on creating healthier communities with better access to nutritious foods as well as safe places to engage in physical activity. A 2007 study by the Trust for America's Health found major savings from community-based prevention programs designed to increase levels of physical activity, improve nutrition, and reduce smoking rates. This study concluded that a national investment of $10 per person per year in these kinds of community-based programs could yield net savings of more than $2.8 billion annually in health care costs in the first 1 and 2 years, more than $16 billion savings within 5 years, and nearly $18 billion savings annually within 10 to 20 years, starting at $10 per person per year. More generally, this bill aims to give Americans the tools and information they need to take charge of their own health. For example, it requires large chain restaurants to post basic nutrition information on the menu so consumers can make healthy choices. That is in this bill. It will start next year. The bill also focuses on prevention and public health needs of a number of generally overlooked populations, including children, individuals with disabilities, Americans living in rural communities, and certain ethnic minorities. For many months I have made the case that it is not enough to talk about how to expand insurance coverage, how to pay the bills--those are important--but it makes no sense to figure out a better way to pay the bills for a system that is dysfunctional, ineffective, and broken. We have to change the health care system itself, beginning with a sharp new emphasis on prevention and public health. We also have to realize that wellness and prevention must be truly comprehensive. It is not only about what just goes on in the doctor's office; it also encompasses community-wide wellness programs, about which I just spoke, things such as building bike paths, walking trails, getting junk food out of our schools, out of the vending machines, making our school breakfasts and lunches more nutritious, increasing the amount of physical activity our children get, and so much more. Some of this is going to be addressed in other bills. For example, next year, in the Agriculture Committee, we will be reauthorizing the child nutrition bill. That deals with school lunches and school breakfasts. We need a major effort there to make our lunches and our breakfasts more nutritious for our kids in school. Next year, in the committee I chair, the HELP Committee, we are going to reauthorize the Elementary and Secondary Education Act, the so- called No Child Left Behind Act. There are a lot of things we are going to be doing on that. I see one of our committee members, the Senator from Colorado, Mr. Bennet, in the Chamber, a former superintendent of schools, who is going to play a key role in helping get that Elementary and Secondary Education Act through and refined and brought up to date where we will make some changes. But there is one other part of that bill we have to focus on; that is, the amount of physical activity kids get in school. I talked many times both to Secretary Duncan and, before him, to Secretary Spellings about this idea of No Child Left Behind. If we are not going to leave kids behind in terms of their writing and their math and their English, how about not leaving them behind in terms of their health? Yet recess is gone. I saw a statistic this year that said 80 percent of elementary school kids in America today get less than 1 hour of physical exercise a week in school--80 percent get less than 1 hour a week. Mr. President, I do not know about you, but I remember when I was in school, in elementary school, we had an hour a day for recess. We had 15 minutes in the morning, 15 minutes in the afternoon, and a half hour at lunch. So there was 1 hour every day, and we had to go out and do stuff. We couldn't sit around and play with Game Boys and things like that. So we got an hour a day of physical exercise. Well, we need to reinvigorate our schools to make sure they get that physical exercise. So we have done a lot in this bill to move this paradigm toward a health care society rather than a sick care society. There is more to do, as I said, in both the Education bill next year and in the Agriculture Committee in terms of the child nutrition reauthorization. But in this bill we have made a great start. We have laid a great foundation. I am just thrilled so many of the wellness and prevention initiatives I have championed for so many years are included in this bill. As I look forward to going to conference, we look forward to working with the House to strengthen it even more and to put more emphasis on wellness and prevention. Just about an hour ago or so, we had a press conference with the president-elect of the American Medical Association, Dr. Wilson. I am proud of the fact that the American Medical Association has now endorsed our bill. As I said at the time, I said the doctors of America have examined this bill, and they have made the right prescription: Pass it. Pass the health care reform bill. But Dr. Wilson, in his statement, made particular note of the wellness and prevention programs we have in this bill. He did not say this, but I was thinking, when he was talking, that it made sense. Doctors want to keep people healthy. They do not want to see people go to the hospital. They would rather be working with their patients one on one. How can they structure a patient's profile so the patient stays healthy, does not get sick so often? That is what Dr. Wilson was talking about: letting doctors practice medicine in a way that focuses on a person's health and keeping them healthy. As President Obama said in his speech to Congress early this year: [It is time] to make the largest investment ever in preventive care, because that's one of the best ways to keep our people healthy and our costs under control. That was the President of the United States in his State of the Union message. Well, President Obama has it right. It is one of the best ways to keep our people healthy and our costs under control, and that is a big part of this bill. I do not know--I have not listened to every speech made by the Republicans on the other side--but I hardly ever hear them talk about this, but it is a very important part of the bill. So, Mr. President, we are changing the paradigm. We are going to extend quality, affordable health coverage to nearly every American. We are going to transform ourselves into a genuine wellness society, and we are going to give our citizens access to a 21st-century health care system, one that is focused on helping us to live healthy, active, and happy lives. Mr. President, I yield the floor.

Mr. HARKIN

Mr. HARKIN. How much time did he ask for, Mr. President?

Mr. HARKIN. No objection.

Mr. HARKIN. I understand now the Democratic side has 1 hour, from 6:30 to 7:30?

Mr. HARKIN. Mr. President, I yield myself the time from 6:30 to 7. Mr. President, I was in my office a little bit ago, and I was watching the comments made by the distinguished minority whip, the Senator from Arizona, Mr. Kyl. He went on at some length about how this vote at 1 a.m. we are going to be taking is tough on some Members. He mentioned specifically our distinguished colleague, Senator Robert Byrd, who is not up and about at those hours, and they would have to drag him out of bed and bring him down here for this vote. Senator Kyl felt very sorry for Senator Byrd that we would do that at 1 a.m. He said the majority leader has the power to put this vote back. We could do it at 9 a.m. in the morning. Well, he is absolutely right; we could do it at 9 a.m. in the morning. But because of the intransigence of the Republican side, because they are not willing to let us have these votes without expending the 30 hours under the rules--under the rules--the cloture motions have been filed and, of course, the Republicans, which is their right, can burn up 30 hours. Well, after the first vote at 1 a.m., the clock starts ticking on the next 30 hours for the underlying substitute. And then after that 30 hours, there is the underlying bill itself, and that gets 30 hours. So if the Republicans really want, they can burn up 90 hours. I ask, to what end? To what end? We have the 60 votes. No one doubts that. There are 60 votes now to pass this bill. So to drag this out and to cause people to come in at 1 a.m. in the morning is not on the Democratic side, it is on the Republican side. So when I heard the distinguished Senator from Arizona pleading to put the vote off, I thought to myself: Well, if that is what the Republicans would like to do, there is a simple way to do that. You simply move the vote we are going to have at 1 a.m. to 9 a.m. tomorrow morning, and then you have the intervening hours from 1 a.m. to 9 a.m. count toward the 30 hours for the next vote. It is simple, very simple. So I took that to heart, and I asked our staff to type up a unanimous consent request, and we have given a copy to the other side. So that is what my unanimous consent will do. It will ask that the vote occur at 9 a.m. tomorrow morning, but that the intervening hours from 1 to 9 would count toward the 30 hours for the underlying substitute. So, Mr. President, I ask unanimous consent that the cloture vote scheduled to occur at 1 a.m. Monday, December 21, occur at 9 a.m. Monday, December 21; and that if cloture is invoked, the postcloture time be considered to have begun at 1 a.m.

Mr. HARKIN. My initial request stands, Mr. President.

Mr. HARKIN. So, Mr. President, here we go again. There they go again. You know, they want to delay, delay, delay, delay; obfuscate, obfuscate, obfuscate, and try to kill this bill by delaying it ad infinitum. They would be happy to delay this through Christmas, through the New Year, and January and February. Why? They would be happy to delay this bill for 10 years or more because they don't want it to happen. That is really what is going on. I say to my good friend from Wyoming--and he is my good friend; he is a great Senator--I thought--we did--in our committee, we got the bill through open and aboveboard. I think the reason we are here at this time is because we Democrats bent over backwards to accommodate the minority. We did in our committee, and I can say that Senator Baucus went the extra mile--no, he went the extra 10 miles. He went the extra 100 miles on the Finance Committee to involve and to get the minority side involved. In the end, only one Republican would vote for it, and we know who that was, the Senator from Maine. We could have emulated the Republicans. We could have emulated what they did when they were in the majority in 2001. I was here. I remember it well. When they came up with this crazy tax package that cut taxes for the wealthiest in our country, stole the surplus we had built up under President Clinton by the year 2000 where we were looking at surpluses on into the future, and they came up with all of these big tax cuts for the wealthy, guess what they did. They didn't involve us at all. They did reconciliation where they only needed 51 votes. Under reconciliation, under the rules of the Senate, as the Presiding Officer knows, there is no filibuster. You cannot filibuster a reconciliation bill under the rules. So if they had done their tax bill in 2001 like we are doing this, we could have delayed. We could have had some input into that, but they said no. They just went right to reconciliation. We could have done that with this bill. We could have done that with this bill. I remember having discussions with members of our caucus and others saying: No, no. And the President, President Obama, wanted to do this as bipartisanly as possible to involve the minority in a constructive process. So that is what we decided to do, to do it in a very constructive, open process. What it has gotten us is total--total-- obfuscation and delay and trying to kill the bill by the minority. But we will persevere. We started this open process, and we are going to finish this open process. The die is cast. We have a vote at 1 a.m. I wish it could be 9 a.m., but you just heard the Republicans object to that because I just asked that the intervening hours be counted toward the next 30 hours, and they wouldn't even do that. So the reason we are here is not because of the Democrats. We are here because the Republicans simply don't want this bill to pass. That is really the reason. So we are going to vote. We are going to vote at 1 a.m. On the face of it, it is really a technical, procedural vote, but it is something more than that. With that vote at 1 a.m. on the managers' package, on cloture on the managers' package, we will have reached a pivotal point at 1 a.m., a pivotal point in a decade-long quest to pass comprehensive health care reform. We have reached a crossroads, a kind of a point in time just as the Senate did in 1935 when we passed Social Security, or in 1965 when we passed the Medicare bill. Each of those bills was a giant step forward for the American people, but each was bitterly opposed in this body by defenders of the status quo, the Republicans. In each case, Senate opponents waged a strident campaign of fear, warning that the passage of the legislation would lead to socialism. Senator Robert Taft from Ohio kept calling it socialism. We are going to ``Sovietize'' America. You can read it in our history books. But in the end, a critical mass of Senators rose to the historic occasion. Senators ignored the dark warnings and the demagoguery. They voted their hopes and not their fears. As we know now, in retrospect they passed laws that transformed America in profoundly positive ways. The Senate has arrived at another one of those rare historic moments. This time, we are attempting to pass comprehensive health care reform, a goal that has alluded Congresses and Presidents going back to the administration of Roosevelt. People think I am talking about Franklin Roosevelt. No. I am talking about the administration of Theodore Roosevelt. Once again, advocates of reform faced bitter opposition, including the filibuster we are seeing now and that has been going on for weeks by defenders of intense interests in the status quo. Once again, each Member of this body must make a choice: fear or hope; stick with the broken status quo or embrace bold change with all of its uncertainties. The other side is saying what about this? What is going to happen here? I keep talking about this bill we are passing. It is not like the Ten Commandments carved in stone. It is a bill. It is a law. Laws change as times and conditions change, as we get different information. So there are uncertainties in the future. The future is uncertain. But we can lay down a good start toward bringing people into a health insurance system and stopping some of the most horrible practices of the health insurance industry, moving us toward more of a health care system rather than a sick care system. So, yes, there are uncertainties, but we know one thing: The certainty of the status quo leads to too many people not having any kind of health care whatsoever. It leads to people dying younger than they should because they don't go in for their checkups and their screenings, children and others. We know the other side made clear sometime ago they wanted to obstruct and delay and filibuster and kill this bill. As far as my friends on the other side of the aisle are concerned, this floor debate is not about offering amendments to improve the bill. It is really not about allowing more time to fully read it and understand the bill. That is nonsense. It is not about playing a constructive role to pass a better bill. All the other side wants to do is kill this bill. Period. All this yakking that is going on--I was home this afternoon and I turned on C-SPAN and I was listening to the debate. And I thought, you know, people are at home. They are getting ready for Christmas. The trees are up. People are feeling good. Here we are going back and forth, back and forth, back and forth, but people have tuned this out. They really have. It is Christmastime and people have tuned this out. Yet we are here. We are here for a good reason. We are here because we are determined to pass meaningful health care reform for America, and we need to do it before Christmas. Well, again, in the defense of the broken system and the status quo, the Republicans joined at the hip with the health insurance companies. They use the same talking points, the same distortions, the same bogus, cooked-up studies, the same outrageous stories about death panels and pulling the plug on grandma. We have heard all that from the other side, week after week, month after month. Every step, as I said, we on this side have acted in good faith. We did not go the reconciliation route. In our futile quest for bipartisanship, we have repeatedly given the Republicans more time. In the Senate HELP Committee, under the great leadership of Senator Dodd, we spent nearly 3 weeks marking up the bill. No amendments were denied. Republicans could offer any amendment they wanted. It took 13 days, a total of 54 hours of meetings. We went out of our way to accommodate our Republican colleagues. We accepted 161 of their amendments, either by vote or just by accepting them. After all that time, all that goodwill on our side, accepting 161 of their amendments, every Republican on the committee voted against the bill. Now, every time I have told this story in Iowa or wherever I have been, people shake their heads. They say: What? They offered 161 amendments? Surely, they would have been kind of happy with that. They might have voted for the bill. They don't understand that. Every single Republican voted against it after all of those amendments. In the Finance Committee, deliberation on the bill stretched out for months solely to accommodate the wishes of the Republican members of the committee. Yet after all that time, despite the fact that Senator Baucus had bent over backwards to pursue bipartisanship and to accommodate the minority's requests--he acted in good faith at every step of the way--all but one Republican on the committee voted against the bill. Now, today, Republican Senators say they are opposing the cloture motion because they need more time. They say we are rushing things, rushing things, there is a big rush going on. Good grief. This bill has been on the Senate floor for 21 days. We have been deliberating about health care reform for almost the entire year. Congresses and Presidents, as I have said, have been trying to get this done since Theodore Roosevelt. So Republican colleagues say: Slow down. You are moving too fast. Well, that is absurd and disingenuous. We have to ask ourselves: Are our Republican friends going to be more constructive, more willing to act in good faith after the Christmas or New Year's break? Of course not. Their aim, understand, is not to improve the bill or to even understand it; it is to kill health care reform. Period. That is all it is. They just want to kill it. Now, because they don't have enough votes to kill it outright, they have opted for a course of delay and obstruction and filibustering. But let's be clear. They are not only delaying and obstructing the Senate; they are delaying and obstructing the millions of Americans who desperately need the reforms in this bill. They are delaying and obstructing the 31 million Americans who will finally get health coverage. They are delaying and obstructing the underinsured, millions of Americans who know they are just one serious illness away from bankruptcy and financial catastrophe. They are delaying and obstructing millions of Americans with preexisting conditions who can't get insurance. They are delaying and obstructing women in this country who face systematic discrimination by health insurance companies. They are delaying and obstructing Americans who fear if they get cancer or heart disease, their health insurance company will cancel their coverage. Let's be clear. Again, Republicans are not only trying to kill health care reform, in doing so they are killing the hope for millions of Americans who are desperate for reform of the current broken system. Too many Americans are literally dying because they do not have health coverage and proper access to a doctor. All told, nearly 45,000 Americans die each year because they lack meaningful health insurance. A Johns Hopkins study found that children without health insurance who are hospitalized are 60 percent more likely to die than those with insurance. Why? It is obvious. Kids without health insurance are much less likely to get preventive care or to be taken to a doctor in the early stages of their illness--60 percent more. Think about that. Children without health insurance who are hospitalized are 60 percent more likely to die than children who have health insurance. So that is the real cost of delay and obstruction on the floor of the Senate. This is our job. We are here. We are going to finish this job. But it is a tragic human cost. And these victims can be found in every one of our cities, our farms, our rural communities. I refuse to allow any obstacle to stand in the way of the Senate addressing the needs of these Americans. I have, along with my friends on this side, opposed the Republicans' filibuster. Likewise, I have been willing to disappoint many whose views I respect by agreeing to painful compromises in order to keep this bill on track. I agreed to those compromises not because I lacked passion or fight--I think my colleagues who know me know well enough that I can fight--I did so because of the harsh but unavoidable reality that because of the Republicans' obstructionism, we need 60 votes to pass this bill, and the only path to securing 60 votes was by making necessary compromises. But I add, that is also the way our predecessors in this body were able to get the votes to pass Social Security and Medicare, both of which had big gaps in coverage when they were first enacted. What they did is they passed bills that were sort of a half a loaf. Then they came back for the remainder of the loaf in the following years. Despite these compromises, make no mistake, this remains a profoundly progressive bill. One analyst put it this way: This legislation will be the most important social policy achievement since the Great Society. That is exactly why the rightwing in this country is pulling out the stops to kill it. This bill will usher in three huge reforms. First, this bill will be the biggest expansion of health coverage since the creation of Medicare. Some 31 million Americans who do not have coverage now will get it, thanks to this bill. This is a monumental achievement. We do this by expanding Medicaid and by providing subsidies to low-income, modest-income families. In addition, if you are a small business owner, this bill will offer tax credits of 35 percent of employer contributions toward premiums in order to make it more affordable for small businesses and their employees to have health insurance. That 35 percent will go up to 50 percent. But the 35 percent starts next year. That is why I have said many times in my State of Iowa, and around it, that actually the biggest winners under this bill, aside from the totally uninsured, are small businesses and the self-employed. Small businesses and the self- employed are the big winners in this bill. What is more, our bill will end the discriminatory practice of jacking up premiums for businesses because an employee is older or has a preexisting condition. They will not be able to do that anymore. Through these new health insurance exchanges, small businesses and people currently without access to affordable coverage will be able to shop and choose from a menu of quality health plans, much in the same way Members of Congress do. This bill does much more than extend health coverage. The second great reform in this bill is an array of provisions cracking down on pervasive, outrageous abuses by the health insurance companies, abuses that currently leave most Americans just one serious illness away from financial catastrophe. Right now, the health insurance industry in this country is extraordinarily profitable. But these profits come at a staggering human cost. Think about it. When Americans get a diagnosis, let's say, of cancer or some other grave illness, they fear two things: First, they fear the illness and, second, they fear the health insurance company. They wonder, is my company going to authorize treatment and pay the bills or will I have to go to war to prevent it from sticking me or rescinding my policy? I always tell people: Look at your policy. Is there a rescission clause in there? I have had so many people say: What is a rescission clause? It is a little clause in there, probably in the fine print, and it says that when your policy is up for renewal, the insurance company can terminate you. They do not have to renew your policy. This is what happens. Someone gets a very serious long-term illness such as cancer or heart disease. When their policy is up for renewal, the insurance company says, no, they will not renew your policy. Now you are out in the cold with a preexisting condition. Now you can't get insurance anywhere. This bill will end that practice. Health insurance companies now employ whole armies of claim adjusters just to deny requests. In fact, the health insurance companies give bonuses--they reward people for denying claims, saying no to policyholders. In the State of California, the largest insurers deny one out of every five requests for medical claims, even when recommended by the patient's doctor. One large insurer, PacifiCare, denies medical claims nearly 40 percent of the time. Think about that. That is almost one out of two. CIGNA denies claims 33 percent of the time. So if you get a terrible illness and you are insured by PacifiCare, good luck in getting them to pay for your medical treatment. Republican Senators give us all the scare talk about a government bureaucrat standing between you and your doctor. Right now, we have corporate bureaucrats standing between you and your doctor, and they earn good evaluations and bonuses and money for denying you coverage. I can remember a town meeting I had in Mason City in August, one of those famous town meetings. Toward the end of it--it was OK. There was a lot of contention there, people voicing their concerns, as they ought to do, as they have a right to do. But at the end, there was a man sitting down in the front. I thought, this will be my last one. I called on him. He stood up and he said: You know, I have been a doctor here for over 40 years in Mason City--40 years. He said: I can say honestly during those 40 years, I have never once had a government bureaucrat come between me and my patients on Medicare or Medicaid. He said: However, I can't tell you how many times during those 40 years I have had insurance bureaucrats come between me and my patients. This is a doctor, practicing for 40 years, and never once did he have a government bureaucrat come between him and his patients. Nearly 62 percent of bankruptcies in the United States are linked to medical bills. And here is the kicker: Nearly 80 percent of those are people who had health insurance. When is the last time you ever heard of a health insurance executive claiming bankruptcy? I would like to find one someplace. The American people have lived in fear and under the heavy hand of these health insurance companies long enough. But help is on the way. Let me mention a few of the ways this bill immediately cracks down on abuses by the health insurance industry. First, if you are uninsured with a preexisting condition, the bill would give you access to affordable coverage without discrimination. Our bill immediately bans those rescissions I talked about where the insurance company can rescind your policy. We stop that right away. We prohibit insurers from imposing lifetime limits on benefits, and we impose and restrict the use of annual limits. Our bill ends discrimination against women. As I said, currently they pay as much as 48 percent more for the same coverage a man has. Our bill requires insurers right away, next year, to let children stay on their family's policy until they are age 26. Those are a few of the things. But there is a third area in this bill I have championed for many years, and in many ways I think it may be the most profound part of the bill, and that is a whole array of provisions promoting wellness and prevention, turning America into a general wellness society. To this end, at the clinical level, the bill requires reimbursement for proven, cost-effective preventive services such as cancer screenings, nutrition counseling, and smoking cessation programs. This means health professionals will be able to offer these services to you before you get diabetes or cancer or emphysema. For essential screenings and annual physicals, there are no copays, no deductibles. We encourage people to do this so they will not have to pay a copay or deductible. Our bill makes major new investments in community wellness and public health, and we help businesses both large and small create workplace wellness programs for their employees. One thing I do not think has been mentioned before, our bill requires large chain restaurants to post basic nutritional information right on the menu so consumers, when they are going out to eat, can make healthy choices. What we are trying to do is change the paradigm from our current sick care system to a true health care system--one that keeps people out of the hospital in the first place. Our aim is to recreate America as a wellness society focused on healthful lifestyles, good nutrition, physical activity, and preventing the chronic diseases that take such a toll. As a proud progressive, I make no bones about my enthusiasm for the three great reforms in this bill--vastly expanding coverage, cracking down on the abuses by the health insurance companies, and making robust investments in wellness and disease prevention. Today we are closer than we have ever been to making Senator Ted Kennedy's dream of universal health insurance a reality. This bill has many authors. We have all been involved in it. But in a very real sense, this is Senator Kennedy's bill. I urge Senators, when the vote occurs at 1 a.m., to vote their hopes, not their fears. Seize the moment. Let's move ahead. Let's vote for cloture. At long last, let's give every American access to the quality, affordable health care they need and they deserve. Mr. President, I yield the floor.

Mr. HARKIN. Objection.

Mr. HARKIN. Mr. President, first, I commend Senator Durbin for his great leadership--he is our assistant majority leader--and for all of his handiwork on this bill. He has been one of our strongest proponents for making coverage more affordable for small businesses. He just spoke about that. In fact, under the managers' amendment, we have expanded, even more than what we did in the original bill, credits for small businesses. These credits now start in 2010. They start next year. They are available to more small business firms than we had in the original bill--all of that, thanks to the hard work and intervention by Senator Durbin. I might note we have a provision also in the managers' amendment relating to cardiac care, congenital heart disease. I know Senator Durbin had a personal tragedy in his own family because of that. So we now have a new program to track the epidemiology of congenital heart disease; it is section 10411, in case anyone is taking notes. It expands on research at NIH on congenital heart disease. We are grateful to Senator Durbin for including that. Basically, of all the things we have for consumer protection, consumers of America have no more dogged champion here in the Congress than Senator Durbin of Illinois. No matter what it is we are passing here, Senator Durbin always looks to see how consumers are affected. He has done that also on this health care bill, by making sure that consumers have better protections and health care is more affordable. I personally thank Senator Durbin for all of his hard work on this bill. As Senator Durbin said, and as our leader, Senator Dodd, said, in about 4 hours--a little less than 4 hours now--the historic vote will take place in the Senate. It will be the defining vote of my Senate career. That has been about 25 years, I guess, I have been here. It will probably be the defining vote for all of us during our tenure here in the Senate. It will be the cloture vote on the managers' package. From that we move forward. I hope after that cloture vote, and after we take that cloture vote, the minority side would see fit, then, since we have the 60 votes, after we have crossed that hurdle, that perhaps they would be willing to close up the debate a little bit sooner than ending on Christmas Eve. But if that is their desire--I mean, they have the rules. We will abide by the rules. If the Republicans want to exercise every single right they have under the rules, they can keep us here until Christmas Eve. There is no doubt about it. But to what end, I ask? To what end? We are going to have the vote at 1 o'clock that is going to require the 60 votes. Then why stay here until Christmas Eve to do what they know we are going to do, and that is to have the 60 votes on the managers' amendment, on the substitute, and on the underlying bill? I hope our Republican leader and others on the other side would perhaps see that it is not in the best interest of the Chamber, it is not in the best interests of the country. I know one of the Senators on the other side was talking about waste today. I am thinking, you know, this is kind of a waste, that we are here yakking about this and doing it up until Christmas Eve, when we could collapse all these votes and get it done tomorrow. We could actually be done here tomorrow with this whole bill if the Republicans would see fit. Like I say, it is up to them. They can keep us here if they want to. But the managers' amendment we are going to vote on at 1 o'clock--again, I keep hearing all day today from the Republicans that they have not had a chance to read it, we are rushing it, and it just came out the other day. The Republicans had it read word for word. The few times I came on the floor during the reading, I didn't see many Republicans over there listening to it. You have to wonder, did they all go home and read it? They made the clerk read it. Why didn't they sit here and listen to it? They would have found out what was in it if they were so interested. Anyway, this is all gamesmanship around here right now. People of America understand that, too. They know we are going to pass health reform, and the first vote is going to be at 1 a.m. this morning. I heard the Senator from Arizona earlier today talking about why should we have it at 1? Why can't we have it at 9 a.m. in the morning? He said the majority leader, Senator Reid, has the power. He could move it to 9 a.m. in the morning and we would not have to bring people here at 1 a.m. He referred to the Senator from West Virginia, Senator Byrd, by name--elderly, frail, but he shows up here to vote. But dragging him out of bed at 1 in the morning to come here? He said, Why don't we do it at 9 in the morning? I thought that was a pretty good idea. When I got to the floor a couple of hours ago, I asked unanimous consent at that time that we have the vote at 9 a.m. but that the hours from 1 to 9 be counted for purposes of the 30 hours. The Republicans objected. So much for their concern for the Senator from West Virginia. We are on the cusp. We are going to expand small business credits. We are going to reduce administrative costs. We are requiring insurance companies to spend 80 to 85 percent of their income on health care--on health care, not fancy corporate offices, not high, expensive CEO salaries of millions of dollars a year, not fancy jets, but 80 to 85 percent must be spent on health care and paying medical claims. As Senator Durbin said, we make major investments in community health centers--10,000 more community health centers in America. We are investing in the National Health Service Corps to get more young people to serve in the National Health Service Corps. We have new protections for patients, access to a primary care provider of their choice, and an important provision championed by the Senator from Maryland--I think Senator Cardin--to provide access for women in their choice of an OB- GYN. In other words, they get to pick who their OB-GYN is, not their primary care provider, not the health insurance company, not anyone else. The individual woman can pick her own OB-GYN. The amendment we have before us immediately allows children to stay on their parents' health insurance until they are age 26. The managers' amendment also prohibits insurance companies from imposing preexisting conditions on children up through the age of 18 right away, next year. Think about that. Think about what that means to a family who has a child who maybe was born with a defect--something that is chronic. The insurance companies tend to exclude them. Our bill says that beginning next year they cannot do that anymore to children. That is a big deal for so many families in this country who have kids who have been afflicted with a birth defect or maybe something happened, maybe they had an accident, maybe they had an illness early in life that has turned chronic. This is a very big deal for those families. Last, for someone like me who represents a lot of rural areas and small towns, we have increased, in the managers' amendment, more workforce. We are going to have more people for rural and underserved communities. We will increase the funding in the training programs for rural health providers, so small towns and rural areas of the country have a big boost in the managers' amendment. We are going to put more money and more loan repayments for people who want to serve in underserved areas, in rural areas, to make sure they do not have to go someplace where they get a lot of money to pay back their debts for medical school. We are going to be providing some of those payments if they serve in a rural area, an underserved area. I know we have now another hour to listen to the Republicans tell us why we ought to put this off for another century or so, I suppose. The people of America know the time has come now. We are committed to this. At 1 a.m., we will have the 60 votes, and we will get this passed before Christmas. It will be one of the best Christmas presents this Congress has ever given the American people. I yield the floor.

Mr. HARKIN. Mr. President, first I thank the Senator from Alaska for all of his hard work on this bill. I think it is fair to say the Senator from Alaska, a new Member of the Senate, I might add, has been very much involved in this bill and his focus has been on rural health and better health care for native Alaskans. As the Senator knows, the Indian Health Care Improvement Act, which also covers Native Alaskans, is included in this bill. I thank the Senator from Alaska for insisting on that and for being a strong supporter of making sure we do help primary care practitioners, both doctors but also nurse practitioners, physicians assistants, other health care and primary health care people who are going to serve in our small towns and rural communities. The Senator from Alaska has been one of our best leaders on making sure that we have this in the bill. I thank him for that very much.

Mr. HARKIN. Let me thank Senator Nelson for his strong commitment to Medicare. I know of no Senator who fights harder for Medicare and for making prescription drugs more affordable to seniors than the Senator from Florida. He has contributed his great expertise as a former insurance commissioner to the provisions we have in this bill on cracking down on insurance company abuses, and he just went through some of them there. I thank my good friend Senator Nelson from Florida for all of his great input into this bill. In a few minutes, the Senate will close its doors for a brief recess. When those doors reopen just after midnight, the Senate will reconvene for a historic purpose: to bring the promise of quality, affordable health care to millions of Americans. When those doors reopen, we who have the privilege of serving in this body will have the opportunity to vote for hope and opportunity and new help for working families who worry every day that their illness will cause them to go bankrupt. Mr. President, I yield the floor.

Mr. HARKIN

Mr. HARKIN. I ask for the yeas and nays.

Mr. HARKIN

Mr. HARKIN. Mr. President, with over 2 million inmates, many who are in prison for nonviolent drug offenses, the United States has the highest rate of incarceration in the world. In recent years, we have rightly begun to question how our criminal justice system can better ensure our communities are safe and free of drugs and violence, while fostering healthy families and communities through drug treatment and rehabilitation for those who are not violent or a danger to society. That is why I cosponsored the Second Chance Act, which became law last Congress. It is also why I am a proud cosponsor of S. 714, the National Criminal Justice Commission Act of 2009, introduced by Senator Webb. As we engage in a dialogue regarding the criminal justice system, I strongly recommend to my colleagues recent remarks Chief Judge Robert W. Pratt of the Southern District of Iowa made before the U.S. Sentencing Commission. Chief Judge Pratt authored the trial court decision in Gall v. United States, where the Supreme Court provided for greater discretion for Federal court judges in imposing criminal sentences, and he has become one of the leading legal thinkers in our country on criminal sentencing. While I do not necessarily endorse every idea Chief Judge Pratt discusses, I commend to my colleagues his incredibly thought-provoking speech on this complex and challenging topic. Mr. President, I ask unanimous consent that the entire text of Chief Judge Pratt's statement be printed in the Record.

Mr. HARKIN

Mr. HARKIN. Parliamentary inquiry: How much time would I be recognized for now?

Mr. HARKIN. Mr. President, today and every day an estimated 14,000 Americans will lose their health insurance coverage. The historic legislation before us takes unprecedented steps to expand this coverage to the great majority of Americans, while cracking down on the abusive practices of the health insurance industry. However, expanding coverage alone is not going to solve our problem. The additional 31 million Americans who will gain coverage thanks to this bill are going to need health care providers, mainly primary health care providers--the doctors, the nurses, the many other health professionals whose skills and hard work provide patients with the high-quality health care they need. We are going to need public health professionals who can provide assistance during times of emergency such as the current H1N1 pandemic. They will need places to go when they become sick, including doctors' offices, community health centers, and nurse-managed health clinics. Today, many communities are facing shortages of primary care practitioners and other health care providers. This map gives an indication of the lack of primary health care providers in America. The darker area is where we have the lowest number of primary health care practitioners. We can see it is mostly rural America. That is not entirely true, but it is mostly in rural America in which we lack that kind of care. Currently, 65 million Americans live in areas suffering from a shortage of these health care professionals. The Department of Health and Human Services estimates it would take more than 16,000 additional practitioners to meet our need. Many of my constituents--and I am sure those of the occupant of the chair--don't have the primary care practitioners they need. I must say, I was up this morning; I was working out; I was watching CNN news. Along came a little blurb: Shortage of primary care health care people in America. That is going to put a crunch on us in terms of meeting our health care needs. People are now beginning to pick up on this all over the country. What are we doing about it? First, we have to recognize some of the root causes. One of the root causes is debt. It is the amount of money health care students pay to go to school. Here is the debt of graduates of medical school: 44 percent have over $175,000 of debt; the vast majority have over $125,000; and some, almost half, have $175,000 of debt. What happens is that with this huge debt, they can't afford to work in rural areas or areas where they don't get recompensed. Qualified applicants are not admitted because of a shortage of faculty members. In 2008, an estimated 50,000 applicants were turned away from baccalaureate and graduate schools of nursing. This is unacceptable. Again, not only do we have to have more primary care practitioners, we need the faculty. It is a growing problem. The Bureau of Labor Statistics estimates that by 2016, we will have a shortage of over 1 million direct care workers, including home health aides, nursing aides, and others who care for our aging population. That is why expanding access to primary and preventative care has been a key focus throughout our health reform efforts. With Senator Murray's leadership of the workforce group, the HELP Committee has focused on expanding resources to increase the supply of qualified health care providers. In the Finance Committee, Senator Baucus also made expanding access to primary care a priority, as well as expanding residency and training initiatives for primary care practitioners. Under Majority Leader Reid's guidance, the Patient Protection and Affordable Care Act, the health reform bill before us, combined both HELP Committee and Finance Committee provisions to expand the health care workforce, especially the primary care workforce. Let's see what this does. First, the bill will train an additional 24,000 primary care physicians via the National Health Services Corps. It provides loan repayment, scholarships, and higher reimbursement for primary care providers in underserved areas. It also increases the supply of public health workers at the Federal, State, and local level, and tribal health agencies. We provide new resources for more community health centers and nurse-managed health centers. We expand primary care residency and training initiatives and hospitals and community health centers. Our bill will improve health care providers' ability to serve our increasingly diverse population by providing training in cultural competency, in working with individuals with disabilities, in providing care within the medical home model. Because innovative health care delivery models such as the medical home emphasize team-based care, we invest in a range of health care professionals, from physicians, to nurses, to dentists, to home health aides, to allied health professionals. In addition, to increase the capacity of health professionals schools and faculty to train new providers, we offer loan repayment programs to doctors, nurses, and dentists who agree to serve as faculty members at medical, nursing, and dental schools. Finally, our bill creates an independent national health care workforce commission to examine and provide recommendations to Congress on how Federal workforce programs can be improved and how Federal dollars can be most effectively spent. It is critical that we act on this historic legislation for many reasons. Most of the debate has been about expanding coverage, cracking down on health insurance abuses, and expanding preventative care to keep people healthy in the first place. But there is also one other aspect of this bill that has not been talked about; that is, what we are doing to increase the number of people whom we are going to have to have for primary care, for our community health centers, for faculty members in the future. This is something we have ignored for far too long at our own peril. We can't forget that while we are expanding coverage--and we are going to cover 94 percent of the American people with this health care bill--while we will make it more affordable, while we are going to protect Medicare, while we are going to do all the things to really make our health system more affordable, more quality-conscious, cover more people, make sure people can get in to their primary care first rather than go to an emergency room, we can't forget that we need the faculty. We need teachers, and we need to help in debt repayment, loan repayments, by giving more scholarships to these young people, the nurses, the nurses aides, the physical therapists, the people who work with people with disabilities, doctors, dentists--the whole panoply of people involved in primary care. We have to help them get through school so they don't have a mountain of debt on their heads, so they can practice medicine where they want, not where they are forced to go in order to pay back their debts. Again, I thank Senator Murray on the HELP Committee, who did so much to put all of this into our bill. This is a major provision of the health care legislation we are not hearing debated about here on the floor very much, but it is one of the most critical parts of the bill. I thank Senator Baucus and all the work they did on the Finance Committee to put in the tax provisions and others to help us, first, invest in and grow the primary care workforce and also to make it possible for people to become faculty members and teachers by helping them pay back their loans and their debts. I wanted to take this time to highlight this part of the bill. It is not talked about much, but I believe it is one of the most important parts of the health reform bill before us. I yield the floor and retain the remainder of my time.

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

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

Mr. HARKIN

Mr. HARKIN. Mr. President, I want to speak for a few minutes on the Labor, Health and Human Services, Education, and Related Agencies appropriations bill. The Senator from Michigan was kind enough to let me do this now, even though she had been on the floor. I ask unanimous consent that at the end of my comments, the Senator from Michigan be recognized.

Mr. HARKIN. Mr. President, as chairman of the subcommittee on Labor, Health and Human Services, Education and Related Agencies, I want to take a few minutes to go over the bill we have before us, the so-called ``minibus.'' I wish in the beginning the Senate could have debated and voted on the Labor-HHS bill individually, rather than having it as part of the so-called minibus. Unfortunately, it is now December. We still have to complete the health care bill and, frankly, we have run out of time. However, I want to assure my colleagues that the Labor-HHS appropriations bill is a bipartisan bill. We worked closely with Senator Cochran and his staff to reflect Democratic and Republican priorities alike. That is the tradition in our subcommittee--one we take very seriously. In fact, the full Appropriations Committee approved our bill by a vote of 29 to 1. You cannot do much better than that to accommodate the concerns of both parties. I also want to assure Senators that this is a fiscally responsible bill. Overall, our bill increases discretionary spending by just 2 percent over the fiscal year 2009 Labor-HHS appropriations bill. With money so tight, we had to be selective about which programs received increases. One high priority is worker protections. Agencies that enforce rules protecting the health, safety, and rights of workers have been seriously shortchanged in recent years. This bill adds $121 million over last year's level and brings staffing levels at the Occupational Safety and Health Administration, the Employee Benefits Administration, and the Employment Standards Administration back to where they were in 2001. This means the agencies will have the resources they need to prevent wage theft and ensure safe workplaces for our Nation's workers. The bill also includes a 50-percent increase--a total $1.1 billion-- to reduce improper payments, fraud, and abuse from mandatory benefit programs, such as unemployment insurance, Medicare, and Social Security. These antifraud, anti-abuse measures could result in over $48 billion in savings and increased revenues over the next 10 years. Another priority we had was getting people back to work. This bill provides an increase of $72 million, or 43 percent, for nurse training programs, including a new program to train nursing home aides and home health aides. This bill also provides a major increase--$260 million--for the national service programs. This will boost the number of AmeriCorps members significantly and create a new social innovation fund that will help small nonprofits tackle a host of social programs. In the area of education, increases are targeted to programs that are designed to reform schools, such as performance-based pay for teachers and principals, charter schools, and a comprehensive new literacy program. Providing increases, such as the ones I have described, meant making some tough choices. Our bill eliminated 11 duplicative and ineffective programs, and we cut several others. Not everybody will be happy with all of those decisions. I may not be happy with all of them, but we did the best we could, struck compromises, and I stand by the outcome. I also support the other five bills in this minibus, if I might say that. I worked closely with our colleagues on the Appropriations Committee. I want to particularly thank Senator Murray regarding her work to allow fiscal year 2009 Community Development Block Grant funds to be used as a match for other Federal programs. The reason this is important is because many States and local governments were hard hit by both disasters--such as the floods in Iowa--and the poor economy. They would have great difficulty providing Federal match requirements without this modification. I thank Senator Murray for putting that in her bill. I also thank Senator Durbin for the inclusion of a provision regarding auto dealers. In my State, there are a number of decisions that were made by General Motors to close down certain dealerships that met the criteria set down by General Motors for staying in business. I hope this provision that Senator Durbin put in will allow for needed fairness for a number of these family businesses. Again, I believe the package of bills we have before us is fiscally responsible. They move our country in the right direction, and I hope the Senate will approve them as soon as possible so we can send them to the President. With that, I yield the floor.

Mr. HARKIN

Mr. HARKIN. Mr. President, I thank my colleague from Montana, the chairman of the Finance Committee, for his great leadership on this issue, on this bill, and Senator Dodd, who took the leadership of our HELP Committee, in putting our bill together. The two of them have done an admirable job of getting our bill this far along and, hopefully, we are going to see the light at the end of the tunnel pretty soon. One of the best Christmas presents we can give the American people is to bring this bill to a close, have our votes up or down and let's get this bill passed so the American people can look ahead to a brighter future in terms of their health care and its quality, affordability, and accessibility. Amendment No. 2939 I wish to take a little bit of time this morning to speak in strong support of Senator Pryor's amendment, which is before us, which would provide information on the consumer satisfaction of health plans offered through the exchanges. The Pryor amendment develops an enrollee satisfaction survey for these plans and requires exchanges to include information from this survey on an Internet Web site. This, too, will allow consumers, both individuals and small businesses, to easily compare survey results and make well-informed choices. Currently, OPM manages an enrollee satisfaction survey for the Federal Employees Health Benefits Plan, the one we are all in and the one our staffs are in, the one that postal workers are in and civil servants all over this country are in. Right now OPM, in managing that plan, has an enrollee satisfaction survey. The Pryor amendment would provide a tool to all Americans that we as Members of Congress have when we select a plan. The survey results could be used by GAO, the Government Accountability Office, and the committee I chair, the Senate HELP Committee, to monitor the quality of exchange plans and fulfill our oversight responsibilities over the exchanges. As a little aside, I keep reminding people we will pass this bill, we will get this health reform bill passed. It will be signed into law. But that does not mean, like the Ten Commandments, it is written in stone, never to be changed. Laws are laws and laws change. They get amended, and we change and adapt as times and conditions demand. As we move ahead and as we look at how the exchanges work, what is happening out there, I have no doubt in my mind there will be some bumps in the road and we will have to come back and revisit it and make some changes. By having this Pryor amendment and what we have in the bill to provide for this kind of survey to see how satisfied people are with the plans, it gives us that kind of oversight ability, that oversight responsibility to look ahead and plan on changes that we will probably be making in the future. But most important, the Pryor amendment will give consumers an important voice. It will keep the insurance companies honest because they will know to maintain and grow their enrollment they must satisfy their customers. This amendment truly complements and reinforces the purpose and function of the exchanges. The Patient Protection and Affordable Care Act, our reform bill, creates exchanges as a place for one-stop shopping where consumers, the self-employed, and small businesses can easily compare plans. This amendment will increase competition and lower premiums as the exchanges will increase competition and lower premiums. This past week, the Congressional Budget Office validated this approach, and the CBO said this about the exchanges: The exchanges would enhance competition among insurers in the nongroup market-- That is small businesses, individuals, self-employed-- by providing a centralized marketplace in which consumers could compare the premiums of relatively standardized insurance products. The additional competition would slightly reduce average premiums in the exchanges by encouraging consumers to enroll in lower-cost plans and by encouraging plans to keep their premiums low in order to attract enrollees. What we have been hearing from the other side of the aisle all along is premiums are going to go up, everything is going to skyrocket. CBO debunked this last week. CBO also said it will benefit small business: Those small employers that purchase coverage through the exchanges would see similar reductions in premiums because of the increased competition among plans. The Senate bill before us ensures consumers and small businesses have the information they need to make informed choices. One, our bill requires exchange plans to provide information on quality measures for health plan performance. This was a provision offered in our committee by Senator Jack Reed, and I commend him for it. Second, our bill develops a rating system that will rate exchange plans based on quality and price--ratings, again, that will be available on an Internet Web site. Third, our bill requires exchanges to operate a toll-free hotline to respond to requests for consumer assistance. Fourth, our bill develops an online calculator so that consumers can figure out how much they will have to pay, factoring in their tax credits and cost-sharing reductions. And fifth, and perhaps most important, I want to acknowledge a contribution made by Senator Dodd in this area. He authored a key provision in our bill to require all plans--all plans--not just exchange plans, all plans--to provide a uniform, easily understandable summary of coverage to enrollees and applicants. In other words, no longer will Americans have to read and try to comprehend the fine print. All of these provisions are currently in our bill to enhance consumer choice, which is what this bill is about--enhancing and expanding affordable choices. Some of them have been overlooked in a lot of the verbiage going on about cutting Medicare and all that stuff, but these provisions will do a great deal to change the way Americans shop for and buy health insurance. This amendment by Senator Pryor will add one more important tool to help our consumers. It is a consumer amendment to make sure consumers get the information they need and the input, a satisfaction survey so consumers can have an input. That way we know here if we need to make changes down the road. I commend Senator Pryor for offering the amendment. I urge my colleagues to support it. I yield the floor.

Mr. HARKIN. Mr. President, I would say that a lot of what Senator Bennett says I agree with. That is why, in this bill--and I keep reminding people because it is not talked about much--there are more provisions in this bill to promote wellness and prevention than any health bill we have ever passed--ever--in the United States. There are huge investments in this bill on prevention and wellness. I happen to think that perhaps one of the reasons Salt Lake City is so good is because people don't smoke and don't drink and that goes a long way toward providing for a healthier form of living. So I say to my friend from Utah, people talk about bending the cost curve only in terms of the spending. I think--and I sincerely believe this--the only way we are going to bend that cost curve is by pushing more of this upstream, by keeping people healthy in the first place, starting with kids and adults, community-based, clinical-based, workplace-based wellness programs. So I ask my friend from Utah to look at that part of the bill.

Mr. HARKIN. First, I thank my friend from Vermont. There is no one who has been leading the charge longer and stronger and more fervently than the Senator from Vermont, Mr. Sanders. I thank him for that. Obviously, we all have community health centers in our States. In Iowa they have been a godsend for so many people in rural areas who did not have access to these kinds of facilities. I remember one time I was in Fort Dodge several years ago. They had a small free clinic there. It was in a church basement one night a week, so people could come in who didn't have insurance and couldn't get access to a doctor. They had one old dental chair there. I think every couple of weeks a dentist would come in for people. A woman had come in who had an abscessed tooth. It was hurting her so much she took a hammer and screwdriver and tried to knock her tooth out. Of course she damaged her gums. That is how desperate people get. Because of that, I got the Fort Dodge community looking at a community health center. They now have a wonderful community health center. They have doctors there, they have nurses there, and people have access to that kind of dental care and health care.

Mr. HARKIN. I thank the Senator again. I can't help but every time we talk about community health centers, I always have to add one thing. A lot of people think community health centers are just for poor people who do not have anything. Nothing could be further from the truth. They will take anyone who walks in the door. You can have health insurance, you can be on Medicare, you can be on Medicaid, you can have no insurance, you can have a great insurance plan--whoever walks in the door. They have a sliding scale based on income, based on resources, of who they will take. It has been my experience--I ask the Senator from Vermont what it has been in his area, but it has been my experience in our growing number of community health centers in my State of Iowa that more and more people----