Tom Harkin

Mr. HARKIN

Mr. HARKIN. Madam President, I ask unanimous consent to be recognized for 7 minutes.

Mr. HARKIN. Yes.

Mr. HARKIN. Madam President, I ask if the Chair will remind me when the 7 minutes is up.

Mr. HARKIN. Madam President, I have to respond to my friend from Wyoming about doing this in a hurry. He mentioned that we did the bill in a hurry in our committee. Actually, it was last November, shortly after the election, when I received a call from Senator Kennedy talking about doing a health reform bill, asking if I would take charge of a section dealing with public health and prevention and wellness. I think then he asked Senator Murray to take over workforce development, Senator Bingaman did coverage, and Senator Mikulski did quality improvements. So that was in November. I cannot speak for the others who did the other sections. All I can say is, on our side, in what I did, we had five hearings. We had five hearings on public health and prevention and wellness and what ought to go into a bill. I think those hearings commenced in December and went through about February. Then we worked until June, and we did not start our markup until June. So we had almost 6 months of hearings and putting things together in the bill before we started a markup. I rather doubt that can be said to be rushing anything. But I just want to focus on the vote that is coming up on the amendment offered by the Senator from Maryland, Ms. Mikulski, which will strengthen provisions in the bill concerning preventive health benefits for women. As an initial matter, I am proud of the significant investments the bill makes overall in wellness and prevention. It has not been talked about very much. If you read the public press out there, the popular press, and watch TV, about the only thing you think is in the bill is a public option and abortion and that is what this bill is about. Well, those may be the hot points and the flashpoints--it makes for good press--but I submit that one of the most important parts, if not the most important part, of this bill is what it does for prevention and wellness, trying to move our costs upstream, keeping people healthy in the first place. I have said many times, what good does it do us if we are just going to pour more money into paying bills for a broken, dysfunctional, sick care system--not a health care system, a sick care system? That is what we have in America today. This bill begins the transformation of moving us from a sick care system to a true health care system. The Senator from Maryland has a very important amendment to make clear--to make clear--that what is included in the bill is to strengthen the preventive services that basically inure to the women of this country. The Mikulski amendment reiterates the recommendations of our bill, and it also points out that the recommendations of the U.S. Preventive Services Task Force is a floor, not a ceiling--it is a minimum. In other words, health plans are required at a minimum to provide first-dollar coverage for preventive services recommended by the Preventive Services Task Force, but that is just the minimum. The Secretary of Health and Human Services has full discretion to identify additional preventive services that will be part of the essential package offered by health insurance on the exchange. Again, there has been some talk here about this task force, the Preventive Services Task Force, that somehow this is a bunch of bureaucrats, it is a government-run task force, it has a political agenda. I have heard all these things said on the floor in the last day or so. Well, in fact, the Preventive Services Task Force is an independent body that evaluates the benefits of clinical preventive services. It makes recommendations--again, no decisions, merely recommendations--about which services are most effective. Who is on this task force? Experts and leaders in primary care who are renowned internists, pediatricians, family physicians, gynecologists, and obstetricians. And these professionals are not located in Washington, DC; they are based all over the country. Some may be in one State or another State. They are all over the country, and they are experts in these different areas, recognized by their peers. They do not sit in an office at Health and Human Services. They bring years of medical training and experience to the jobs they do. Does that mean they never make a mistake? No. No one is perfect. No Senator is perfect. Neither is every doctor perfect. And neither is any task force always going to make what we might consider to be the perfect answer. But our bill does not grant them the authority to tell insurance companies what not to cover. That is clear. But to hear the debate on the floor, you would think it is just the opposite, that the Preventive Services Task Force can tell insurance companies what they cannot cover. That is not true. Our bill says that those recommendations that are A and B--categorized by the Preventive Services Task Force, by these expert doctors around the country--these are the ones they say really are key preventive services, have the most benefit. We say in our bill that those services must be covered without copays, without deductibles. That means that is the floor. That is the floor. Again, I might also add that preventive services that are rated by the Advisory Committee on Immunization Practices and comprehensive guidelines supported by the Health Resources and Services Administration are also part of the recommendations to establish that floor. So, again, I would say it is a pretty big floor when you put all those together. Again, it does not establish a ceiling and it does not say what cannot be done. It just says you have to do these basics. That is the floor. I do understand the concerns of some that the task force has not spent enough time studying preventative services that are unique to women. Senator Mikulski goes back a long way on this issue. I can remember some years ago Senator Mikulski pointing out to me, in my capacity as the then-chairman of the Appropriations subcommittee that funds NIH----

Mr. HARKIN. Madam President, I ask unanimous consent for 3 more minutes.

Mr. HARKIN. Senator Mikulski said: If you look at the research being done at NIH, it is almost all done on men and not on women. I remember that some years ago, and all of a sudden a lightbulb went off in my head. I said: You are right. So we had to start changing the focus of a lot of the research done to focus on the unique situations faced by women. Well, this was also a concern that was raised in our HELP Committee by Senator Mikulski, and we included language to require all health plans to cover comprehensive women's preventive care and screenings based on guidelines promulgated by the Health Resources and Services Administration--again, without any copays or deductibles. That was in our health bill but unfortunately was not included in the merged bill. But Senator Mikulski's amendment, which we are about to vote on, brings us back to the position we had in the HELP Committee bill. I think that was largely supported, if I am not mistaken, on both sides, at least in our HELP Committee. At least no one offered any amendment to strike it when we were debating it in committee. So I assume it was supported generally by both Republicans and Democrats. By voting for the Mikulski amendment, we can make doubly sure that the floor we are establishing in the bill for preventive services that are unique to women also has no copays and no deductibles. Again, that is why this amendment is so important. I know our friend Senator Murkowski has a different way of approach. I commend her for her involvement and her interest in this issue. She has been a great member of our committee, and I have done a lot of great work with Senator Murkowski. But I think her amendment misses the mark in this way: It asks insurers to use guidelines from provider groups when making coverage decisions. Well, that does not guarantee women will get any of the preventive services they need. Here is a statement from the American Heart Association and the American Stroke Association. It says: . . . we are concerned that Senator Murkowski's preventive health services amendment would take a step backwards by substituting the judgment of the independent U.S. Preventive Services Task Force with the judgment of private health insurance companies. Madam President, I ask unanimous consent that this letter from the American Heart Association and the American Stroke Association be printed in the Record.

Mr. HARKIN. Madam President, I will have more to say about the Murkowski amendment later. But, again, the point is, the Mikulski amendment is right on point. It should be adopted.

Mr. HARKIN. How much time would the Senator like to consume?

Mr. HARKIN. I am deeply saddened that my Republican colleagues have, now we see very clearly, resorted to fear tactics in their desperate attempt to preserve a dysfunctional, costly, status quo medical system that we have in this country today. Republicans, in their attempt to strike fear in seniors across the country, are trying to convince the people that they have changed from the party that has always opposed Medicare to now being Medicare's staunchest defenders. But we all know, if it were up to our friends on the other side of the aisle, there would be no Medicare. They fought its very creation. Don't take my word for it, take one of their standard-bearers who ran for President. Senator Bob Dole, who was here when we created Medicare, Senator Dole, a friend of mine--I have a good deal of admiration for Senator Dole-- said, ``I was there, fighting the fight, voting against Medicare--one of twelve--because we knew it wouldn't work in 1965.'' He said that in 1995 when he was running for President. He was proud of the fact that he and Republicans had opposed the establishment of the Medicare system. You might say: That was then, what about recently? Here is the former Speaker of the House, Newt Gingrich. He said, ``We believe it's going to wither on the vine,'' speaking of Medicare. Now my friends on the other side of the aisle--listening to them, you would think they were the biggest supporters of Medicare forever, when they opposed it from its very beginning. Now we hear all the stuff about Medicare Advantage. If, in fact, we are going to be cutting a little bit out of Medicare Advantage, they would like to tell you that somehow this is going to ruin Medicare. If that were true, why would the National Committee to Preserve Social Security and Medicare, AARP, the alliance for retired Americans, groups that represent tens of millions of seniors--why would they stand with us in support of our bill and not with the Republicans, who want to gut the very provisions we have in there that will strengthen and preserve Medicare? Do people really believe our Republican colleagues care more about seniors than these groups that actually represent seniors? The truth is, when we talk about Medicare Advantage, we are talking about private insurance companies who promised that through competition they were going to deliver better quality health care to seniors at a lower cost. It all sounded good. But what has happened since Medicare Advantage has come in? The reality is, Medicare is now paying on average 14 percent more to these private plans than it would cost to cover the same beneficiaries under traditional Medicare. In some cases, it is as high as 50 percent more. That is $12 billion a year more than if these beneficiaries stayed in Medicare. Basically, we are giving a $12 billion subsidy to these companies. Again, don't take my word for it. This is from a June 2009 MedPAC report: We estimate that in 2009, Medicare paid about $12 billion more for enrollees of [Medicare Advantage] plans than it would if they were in [fee-for-service] Medicare. A $12 billion slush fund. We are saying we are going to reduce some of those subsidies. I hear my friends on the other side: My gosh, Medicare is going to take away all these benefits, and all that other kind of stuff. Not necessarily. Right now we know, according to CBO, our bill will lower seniors' Medicare premiums by $30 billion over 10 years. Then the other side says: But if you cut these Medicare Advantage payments, you will see their benefits cut. That is absolutely not true. All Medicare plans, whether traditional Medicare or private, must offer all required Medicare benefits. Here is the kicker. If, in fact, there are some cuts made in Medicare Advantage, then these private companies that are making $12 billion in their slush fund, maybe rather than cutting benefits, maybe they will decide to cut their CEO salaries from $12 million a year to $10 million a year. Maybe they will decide instead of three or four corporate jets, they only need one. Maybe they will start reducing some of the profits they are making, huge profits they are making off of the taxpayers and off of Medicare payees right now. Again, if we cut the Medicare Advantage Program, I guess my friends on the other side would say, No. 1, they can continue to pay their CEOs $12 million a year salaries. They can continue the corporate jets. They can continue to have fancy buildings. They can continue to have outrageous profits. But they will have to cut Medicare. That is what the other side is saying. We are saying: No, cut the CEO salaries. Cut the enormous profits. Cut those corporate jets. Cut all of that stuff you are using the slush fund for, but keep the benefits for Medicare. As I said, under present law they cannot cut the basic Medicare benefits. No senior anywhere in America will lose their core Medicare benefits under our bill. Let's be clear about that. If they did, AARP, the National Committee to Preserve Social Security and Medicare, and the National Alliance for Retired Americans would never be supporting our bill. Lastly, according to an economic survey done at Boston University, they extensively analyzed Medicare Advantage payments and found that just 14 percent of the additional funds these private plans have received have gone to benefit Medicare enrollees. The vast majority of the payments, 86 percent, go to profits, CEO salaries, corporate jets, all these other things, or some of it may go to things such as gym memberships, spa memberships. I raised the point the other day. Why should my Medicare beneficiaries in Iowa have to pay more in Medicare so that a Medicare beneficiary, say, in Arizona can go to a spa and have it paid for by Medicare Advantage, paid for by the subsidies of $12 billion that we give them that come both from taxpayers and from Medicare recipients right now? I don't think it is fair for my seniors in Iowa to have to pay for that. A lot has been said about all the people who are in the Medicare Advantage plans. I looked up the figures. Right now, nationally, only 18.6 percent of all enrollees are in Medicare Advantage, a little less than one out of five. In my State, in Iowa, it is 10 percent, 1 out of every 10. Why is that? We don't have a lot of spas in Iowa. We don't have those fancy things like they have in Florida and Texas and Arizona and California, wherever else all this stuff is going. What my seniors need is the peace of mind of knowing that Medicare is going to be there for them in the future. They need to know they are going to get the benefits we have put in this plan that are in our bill and that will help Medicare beneficiaries. Here is what they are. AARP says: The new Senate bill makes improvements in the Medicare program by creating a new annual wellness benefit, providing preventive benefits and, most notably for AARP members, reducing drug costs for seniors who fall into the dreaded Medicare doughnut hole. The bill also makes improvements on age rating, a discriminatory practice that allows insurers to charge exorbitant age-based premiums to older Americans. Finally, AARP strongly supports provisions in the Senate bill to strengthen long-term services and supports. We also applaud inclusion of provisions to improve access to Medicaid home and community-based services. All is in our bill, all of which would fall if we adopt the McCain amendment. I urge colleagues not to listen to the rhetoric from the other side. Listen to those who really do represent seniors. Make sure we preserve and protect the basic Medicare functions for seniors and for those who are about to retire. You will not get that through Medicare Advantage. If Medicare Advantage wants to exist and compete on a level playing field, God bless them. Go ahead and get it done. That is what we were promised when Medicare Advantage came through here. I remember. Competition. But what we found is, we had to cough up an additional $12 billion to subsidize them. It is time for us again to say no to the fearmongers, to those who are trying to strike fear in seniors. It is time to stand up, support the Bennet amendment, which makes very clear that any savings that come from Medicare has to go back into Medicare. That is the way it ought to be. That is what is in this bill. The Bennet amendment makes that crystal clear. The McCain motion does away, basically, with all of the protections, all of the things we have worked so hard for since 1965 to provide. The McCain motion, when you strip away all the verbiage, really what it does is, it basically takes us back to pre-1965 when we didn't even have Medicare. That is the kind of intent behind it.

Mr. HARKIN. I am glad to yield.

Mr. HARKIN. As I said earlier, what they are talking about in preserving these benefits and this subsidy for Medicare Advantage is the big CEO compensation packages, the corporate jets, the fancy buildings, the high profits, somewhere between 30 percent and 200 percent profits made by these companies that are providing Medicare Advantage. That is what the Republicans are trying to protect, not the Medicare recipients.

Mr. HARKIN. I move to lay that motion on the table. The motion to lay on the table was agreed to.

Mr. HARKIN

Mr. HARKIN. Parliamentary inquiry: What rule are we under right now? How much time do we have? Are we under any time constraints?

Mr. HARKIN. Mr. President, first I wish to thank my colleague for all the work he did in our committee. I am sorry he is not still on our committee. I wish he were. But a lot of the good work we have in our bill is due to Senator Whitehouse's involvement in the development of this bill. He was a great member of our committee, and as the chairman, I sure wish he would come back. That is all I can say. I say to the Senator, thank you for all the great work you did on this bill and especially all the wonderful work you did on getting us the public option that we had in our bill that was adopted by the House but also all the great work you did on making sure we had a robust prevention and wellness program in our bill. I have always said that the best way to bend the cost curve is to keep people healthy in the first place and keep them out of the hospital. So I thank my colleague for all his great work on the bill.

Mr. HARKIN. Mr. President, I would like to engage my friend from Pennsylvania in a little discussion on one part of the bill that was mentioned earlier today but really has not received much attention. I think there are some misconceptions about what it does. It is called the CLASS Act. Basically, the CLASS Act is a bill that was championed by Senator Kennedy for many years. It has its genesis in the kind of convoluted system we have now in how we provide for people who become disabled. Either through their work, through an accident, through illness, or whatever, people become disabled. As you know, we have a portion of that under the Social Security system, disability insurance. But, in fact, it does not take care of any kind of long-term care. So Senator Kennedy, for many years, championed the idea of giving people the ability to set aside some money during their working years that would be sort of like Social Security. It would vest, and then, if, God forbid, they became disabled, they would then have a certain monthly income that would enable them to live in their own homes, live in their own communities, and to ease some of the burdens of their disability. Before he passed away, Senator Kennedy talked to all of us on the committee about his dream and his hope that we would have this incorporated in our health reform bill. Well, we did this in the HELP Committee. We brought it forward. We had it scored. We know exactly how it operates. As we will make clear, I am sure, in our colloquy, it is a program that can be paid for. It is voluntary, as we said. It will stand on its own two feet. It is not another entitlement program, as I heard someone say here earlier today. In fact, it has to be self-financing by the premiums people pay in during their working years. It is an affordable, long-term care program. Again, it will allow families to plan for any possibility of a chronic illness, without having the fear of being put in a nursing home. As I said, it is voluntary. The CBO gave us a scoring on this that it was actuarially sound for 75 years--actuarially sound for 75 years. What that means is that the premiums paid in and the benefits paid out will be kept in proper alignment. It will be fully solvent. Quite frankly, Mr. Gregg, the Senator from New Hampshire, on our committee, basically talked about this, and here is what he said: I offered an amendment, which was ultimately accepted, that would require the CLASS Act premiums to be based on a 75-year actuarial analysis of the program's costs. My amendment ensures that instead of promising more than we can deliver, the program will be fiscally solvent and we won't be passing the buck--or really, passing the debt--to future generations. I'm pleased the HELP Committee unanimously accepted this amendment. Well, we did, and that is why I make the point that this is not another entitlement program, as was said here earlier today. Even better, the CBO believes the CLASS Act will save Medicaid $1.4 billion in the first 4 years alone--$1.4 billion in the first 4 years alone--as a result of families who will be paying into and then using the CLASS benefit instead of Medicaid to similarly pay for the help they need to remain at home. That is really what people want. People want to stay in their own communities. They do not want to have to go to a nursing home. The CLASS Act would provide money for assisted transportation, in- home meals, help with household chores, professional help getting ready for work, adult daycare, professional personal care. Now, will it pay for all those things? No, it will not pay for all those things, but it will give you enough of a basic support so that, coupled with other things, you would be able to stay at home and maybe even go to work. You may be disabled, but you may not be so disabled you cannot do some work; therefore, you need a little bit of help at home to get out in the morning and go to work or maybe you just need some personal assistance care that would enable you to stay in your own home rather than going to a nursing home. So that is why this amendment is so important. It is voluntary, long overdue. I think it will begin to give people the peace of mind of knowing if they pay into this system, after it vests--after 5 years of vesting--they will then be able to access this program in case they get disabled. Mr. President, I see my colleague and my friend from Pennsylvania is on the floor, a strong supporter of the CLASS Act and what we are trying to do here in terms of giving people the ability to maintain themselves if, God forbid, they should become disabled. I will be delighted to yield whatever time he needs to the Senator from Pennsylvania and engage in any colloquies he would like.

Mr. HARKIN. I thank my friend and my colleague from Pennsylvania for laying out why this is so important, the fact that we are actually going to get savings for Medicaid from this. That is helping the States. That helps the States a lot. So we get a lot of bangs for the buck, as one might say, with the CLASS Act that we have in this bill. I say to my friend from Pennsylvania I think one of the biggest concerns people have--they may not express it when they are younger, but once they start working and they start having a family and they see one of their friends, a relative, someone in their neighborhood, become disabled--and believe me, it happens in our neighborhoods, it happens to our friends--they see that and they wonder, Maybe but for the grace of God there go I, but what would I do if something like that happened to me? How would my family, my children function? Where would the money come from? So to be able to have the peace of mind, to know there is a program whereby they can put some money aside every month, voluntarily, for 5 years, and then after that, they would then be able to access money if they got disabled--talk about a great insurance program. Talk about the peace of mind this would provide for people. As I said, as we both have pointed out, this is actuarially sound for 75 years. So it seems to me that for all of these reasons, including the savings in Medicaid for the soundness of the program, but also for the peace of mind for people who are working, to know they now have a program, something they can access, that will provide them--again, I don't want to sell this for more than it is. This is not something that will make someone 100 percent whole from their earnings. We are not trying to tell people that. What this will give them is up to $75 a day to help them with all of the things I pointed out: maybe getting up, getting ready to go to work; maybe it is personal attendant services. It could be a whole host of different things that will enable them to live in their home, in their community, and, yes, maybe even be able to go to work every day. My friend from Pennsylvania referred to the story I told earlier this summer, and I like to tell it because I think it illustrates what we are talking about here. I have a nephew, Kelly, my sister's boy. Well, he is not a boy anymore; he is an older man now, I guess you might say. He became disabled at a very young age, age 19, a severe paraplegic, but he was able to go to school, go to college. He was able then to live by himself in his own home. He had a van with a lift. He could get his wheelchair up there and punch the button and the doors would open and the thing would come down and he would get in the van. He had use of his hands. He could drive to work. He was able to start his own small business. But every morning he needed a nurse to come into the home, get him ready to go to work, get him up, get him going, get him out the door. Every night when he came home, he would stop and do some shopping on the way, come home to his own house where he lived, in his own community, among his family. His family was close by. They would have a nurse every evening do his exercises with him, keep his arms strong, do all of his other internal things that needed to be done, make sure he could get to bed. It happened every day. But because of that, he was able to live a full life, and he still is. Kelly is still an active man. But that was--gee, I am trying to remember now. I have to think. That was in 1979, 30 years ago. Kelly must be about almost 50 years old now. I never thought about that. I always think of him as a kid. But he was able to do that, and he has lived a full life. He has been able to work, live by himself, do all kinds of wonderful things. How was he able to afford this? Was his family wealthy? Not a bit, not at all. In fact, his mother died shortly after the accident happened. My sister, who had breast cancer, died at an untimely, young age. But the way Kelly was able to do all this was because he got injured in the military. He got injured while he was onboard a ship off the coast of Vietnam. So the VA paid for all of this and is still paying for it--for his personal services--so that he can live by himself and get out the door and go to work. I have seen what that has done for him. I thought to myself: Well, if we can do this for veterans, what about other people in our society who, through no fault of their own or through an accident or whatever, become disabled. I thought about how much Kelly was able to earn during his lifetime, the fact that he paid taxes, had his own business. You know, that was a pretty darn good deal for the taxpayers of this country. In a small way, that is what we are trying to do here. That is what we are trying to do, to build a system for someone who gets injured, becomes disabled, has some support mechanisms so they can also live a full, rich, and happy quality life without having to go to a nursing home. That is what this is all about. As I said before, I say to my friend, it has so much to offer. I can't imagine there would be any real opposition to this--voluntary, actuarially sound. It provides a stipend to help people if they become disabled. I say to my friend from Pennsylvania it seems to me of all the things we have been discussing on this health reform bill so far, to me this is one of the most important. This is one of the most important parts of this health reform bill. We have never done it before. It is long overdue. It will be good for our families. It will be good for businesses. It will help our States because of the cutbacks and they won't have to pay so much into Medicaid. I thank my friend from Pennsylvania for his strong support of this. I say to my friend Ted Kennedy: We are going to get it done. It is going to happen. We are not going to let this bill get through and go to the President without having this in it. It is going to be there. There is no doubt about it. We are going to make it work, just as the Veterans' Administration worked for my nephew Kelly. I yield back to my friend from Pennsylvania. Actually, he asked me a question and I kind of got off a little bit there on telling my stories.

Mr. HARKIN. That is right.

Mr. HARKIN. If the Senator would yield again to me, two other things. I am glad the Senator mentioned Connie Garner who again, with Senator Kennedy, has worked so many years on this, and has her own personal story to tell regarding this, a very poignant story. But I now want to thank Connie for all of her wonderful work on this and shepherding this through. She is probably sitting over there wishing we had said this and that, because we probably forgot something she knows better than we know. But we do our best, Connie. We do our best with what we have, anyway, to try to explain this. But I thank Connie for all of her great work and leadership in getting this to this point. I wonder if I might impose upon the Senator, if I might--not digress but talk about one other part of the picture here we are talking about, in terms of covering people with disabilities. We have been talking about the CLASS Act, which is prospective. It looks ahead; it provides the mechanism whereby middle-class families can plan for the future possibility of an illness or a disability by putting this money away every month. We have talked about that. But one might ask the question: What about those who are disabled now? What is happening to them, the millions of Americans who are already living with a disability? Well, in 1990, we passed the Americans With Disabilities Act. We began to break down a lot of barriers in terms of people with disabilities and accessing daily living, accessing employment, transportation. But what happened was a few court cases started interfering with this. There was one court case in particular called the Olmstead decision 10 years ago. It came out of Georgia. It was a case in Georgia. It went to the Supreme Court. The Supreme Court said that based upon the Americans With Disabilities Act, a State had to provide the least restrictive environment for a person with a disability. Well, this was wonderful because the only option for many people with disabilities right now is to go to a nursing home. In fact, our Federal laws are basically skewed toward putting people in nursing homes. Let me explain. Right now, about the only support a person with a severe disability has is through Medicaid. As you know, through Medicaid you have to spend down until you become poor and then you get access to Medicaid. But under our laws, Medicaid must pay for you, if you are disabled, and then you qualify--they must pay for you to be in an institution or nursing home. They must. They have to pay for you. If, however, you are a person with a disability and you say: But I don't want to live in a nursing home; I would like to live--like my nephew Kelly--in my own house with my friends, in my own neighborhood, Medicaid doesn't have to pay for it, and in most cases it does not pay for that. In the vast majority of cases, it doesn't pay for that. So their beginning movement was in the mid-1990s to provide for funding for individuals with disabilities so they can live in their own homes in the community and not have to go to the nursing home. Well, that bill never--it was called MCASSA, the Medicaid Community Attendant Support and Services Act. I always like telling people, I say to my friend from Pennsylvania, while we sponsored it over in the Senate, the first sponsor of it in the House was the Speaker at that time who had taken over, and his name was Newt Gingrich. To this day, he is still supportive of that. A few years ago, I talked to him, and he was still a strong supporter of MCASSA. It later became the Community Choice Act. We could never get it enacted into law. It is a part of this health care reform bill in this way: It provides that if a State implements this Community Choice Act, which would allow people with disabilities to live in the community rather than in a nursing home, it will then get a bump up. It will get a 6-percent increase in its Federal match for Medicaid. As you know, now the Federal Government provides some and the State provides some for Medicaid. It is roughly 60/40. It varies a little, but that is roughly it, 60/40. Well, that means that a State now that would do this would not have to come up with its 40 percent; it would only have to come up with 34 percent. So it is an incentive for States to begin to implement the Supreme Court decision of over 10 years ago that people with disabilities have a right to live in the least restrictive environment. Again, Medicaid, right now, as I said, will provide only for nursing home care. States are obligated to pay for that. They must. Again, this also is a part of what the elderly in this country are concerned about too. A lot of them say that if they become disabled, they don't want to go to a nursing home, but that is their only option under Medicaid. So that explains why the second biggest priority in poll after poll for seniors in this bill, after strengthening Medicare--which we do--is changes to the health care system that will allow them to get the help they need to stay at home rather than going to a nursing home. Again, you might say, why is this so important? Well, a couple of stories. Two women who brought the Olmstead case, Lois Curtis and Elaine Wilson, when asked at a hearing what it changed for them, because they were no longer institutionalized, both spoke of things that we kind of take for granted: They had new friends. They could meet new people. They could attend family celebrations. They said: We could make Kool-Aid whenever we wanted to. Simple things. They could go outside and walk in the neighborhood. They got a little dog, and they could walk the dog in the neighborhood--something they could not do in the nursing home. That is another part of the bill--very closely aligned with the CLASS Act, but it pertains to those people with disabilities right now. We know, again, from data and statistics we have that by paying for personal care services and home care services--and you might say that is really expensive. But we know from data that we get three for one. In other words, for every one person in a nursing home, for what that costs, we can provide community and home-based services for three people. That is three people for every one in a nursing home. So in a way, yes, it costs money, but for every person we get out of a nursing home, we can pay for three living in the community. Again, that is not to mention the kind of quality of life I just mentioned. This bill for the first time creates the community first choice option, which gives States an extra share of Federal money--6 percent-- if they agree to provide personal care and services to all eligible people in their State--I mean those eligible for institutional care. If they provide that to them, then they get a bump up. And only by making personal care services available on an equal basis to all those eligible can we satisfy the promise of the Americans with Disabilities Act and really meet the Supreme Court mandate in the Olmstead decision. I say to my friend from Pennsylvania, there are two aspects of the bill. One is the CLASS Act, which looks ahead and provides that peace of mind that people know they can have that access. Then we provide for people with disabilities who are living out there, fearful that the only thing that will happen to them is they will have to go to a nursing home. Now we are going to say to States: You provide community- and home-based services, and we will give you more money to do so through your Medicaid Program. Hopefully, with that, the States will begin to move more rapidly to fulfill the mandate of that Supreme Court decision. I thank my friend for yielding me this time to explain that.

Mr. HARKIN

Mr. HARKIN. Well, Mr. President, sitting here listening to the Senator from Arizona and the Senator from Oklahoma go on, I hardly know where to start. There have been so many accusations and so much misinformation it is hard to know where to begin. I would begin by, first of all, saying the people who keep saying we are slashing Medicare and we are going to harm seniors are totally wrong. The fact is, the bill we have before us protects Medicare's guaranteed benefits, reduces premiums and copays for seniors, ensures that seniors can keep their own doctors, and ensures Medicare will not go broke in 8 years by stopping the waste, fraud, and abuse. I might also say, as an aside, every time I hear the Senator from Oklahoma talking about waste and abuse and fraud in Medicare, it sounds like it is all in Medicare. The waste, fraud, and abuse we are talking about are the ripoffs of Medicare by pharmaceutical companies, many of which have been fined big fines and have settled. One of the most recent ones, I think, was almost for a billion-some dollars. It was one of the largest settlements in our history with a pharmaceutical company that was caught ripping off Medicare. And insurance companies have ripped off Medicare, and others. It is not within Medicare; it is those who are coming at Medicare and trying to plunder it. But that is what we do in this bill: We are stopping that kind of waste and abuse against Medicare; not in Medicare but against Medicare. We provide new preventive and wellness benefits for seniors. We lower prescription drug costs, keep seniors in their own homes, and not nursing homes, with the CLASS Act and the Community Choice Act that is also in this bill. When they talk about going after Medicare, boy, talk about crocodile tears. Was it not Newt Gingrich, the former Speaker of the House, the leader of the Republican revolution, who said he wanted Medicare to ``wither on the vine''? Was it not Senator Bob Dole, their standard bearer for President in the 1990s, who said he had fought against Medicare and was proud he voted against it? Now, all of sudden, it seems as though Republicans are the guardians of Medicare. People know the truth. The American people know the truth. They know it is the Democrats who fought for Medicare. Lyndon Johnson, as President, and the Democrats in the House and Senate, if it were not for them, Medicare would have never been passed. It is the Democrats who have fought to keep Medicare alive and well and healthy, and expanding it to people all over this country every step of the way-- being opposed by our friends on the other side of the aisle. And now to hear them talk about how much we are going after Medicare, boy, talk about crocodile tears. The other thing I want to say is that I want to correct something the Senator from Oklahoma said. He talked about the recommendations that recently came out--I will have more to say about this in a minute--on mammograms. He said the U.S. Preventive Services Task Force--all they did was look at costs. That is what the Senator said. They looked at costs but they did not look at the people. Recommendations that come from the U.S. Preventive Services Task Force cannot take into account cost. Cost cannot be a factor. They can only look at scientific evidence, safety, and efficacy. Cost cannot be taken in as any factor in their deliberations. So I wanted to set the record correct on that. As I said, there were so many things I heard from the other side it is hard to know where to start. I see my leader here, Senator Dodd, who did such a great job in getting our bill to the committee and getting it in the form that it is now and on the floor. I wish to ask the Senator--I know the Senator was here listening to our friend, the Senator from Arizona, speak. Did it strike you that what he said was kind of missing the mark here a little bit and maybe not quite what we are doing in this bill?

Mr. HARKIN. Mr. President, the only thing I would say to my friend from Connecticut--he said that in 2005 we had made all of these cuts in the Deficit Reduction Act. I just want to say for the record that I didn't vote for it and neither did the Senator from Connecticut.

Mr. HARKIN. Is this not when the Republicans were in charge and they had a Republican President and a Republican House and Senate? That is when they cut all the mammogram screenings and things such as that?

Mr. HARKIN. I thank my friend for pointing out those facts. Mr. President, I have a letter dated December 1, 2009, from the National Committee to Preserve Social Security and Medicare. It says: Dear Senator: On behalf of the millions of members and supporters of the National Committee to Preserve Social Security and Medicare, I am writing to express our opposition to the amendment offered by Senator McCain which would recommit the bill to the Senate Finance Committee. Much of the rhetoric from opponents of health care reform is intended to frighten our Nation's seniors by persuading them that Medicare will be cut and their benefits reduced so that they too will oppose this legislation. The fact is that H.R. 3590, the Patient Protection and Affordable Care Act-- The bill we have before us-- does not cut Medicare benefits; rather, it includes provisions to ensure that seniors receive high quality care and the best value for our Medicare dollars. This legislation makes important improvements to Medicare which are intended to manage costs by improving the delivery of care and to eliminate wasteful spending. I won't read all of it, but it concludes: The committee urges you to oppose the motion to recommit the bill to the Finance Committee. Sincerely, Barbara B. Kennelly, President and CEO. Mr. President, I ask unanimous consent to have this letter printed in the Record.

Mr. HARKIN. Mr. President, I wish to talk about the amendment before us which has been offered by the Senator from Maryland, my colleague, Senator Mikulski. I am going to have more to say about the bill and engage with, perhaps, the Senators from Arizona and Oklahoma in the days and weeks ahead on the structure of the bill itself, but I wish to focus on the amendment that is now before us. First of all, I am proud that this bill, the Patient Protection and Affordable Care Act, makes significant investments in prevention and wellness because I have long believed that such investments are essential for transforming our sick care system--that is what we have now, a sick care system--into a true health care system, one that keeps Americans healthy in the first place. It keeps them out of the hospital. It will keep a check on rising costs in both the public and private health care markets. It does this in a number of ways. I won't go into all of them, but among the most important is that this bill requires insurance companies to cover highly effective preventive services with no copayments or deductibles--no copayments or deductibles. This is critical because we know that all too often people forgo their yearly checkups or screenings either because their insurance company doesn't cover them or, secondly, because they have high copays or deductibles that make them simply unaffordable. For example, I had a recent conversation with a small business owner in western Iowa, and he and his few employees have a $5,000 deductible. He recently turned 50. His doctor said: Time for you to get your first colonoscopy. Well, he found out that the colonoscopy was $3,000. He has a $5,000 deductible. This is all out-of- pocket. So not being a man of wealth and not having a lot of means, trying to struggle to keep his small business afloat, he is putting it off. He is putting it off. So that is what is happening now. But what we say in our bill is that these have to be covered without copays or deductibles. There has been a lot of discussion recently on the coverage of preventive services for women in light of the recent recommendations issued by the U.S. Preventive Services Task Force on mammogram screenings. It has been alleged that the Reid bill, like the HELP and Finance bills that preceded it, only requires coverage of those services strongly recommended by the Preventive Services Task Force. This simply is not true. Under the language of this bill, health plans are required at a minimum--at a minimum--to provide coverage without cost for preventive services recommended by the Preventive Services Task Force. Understand that. It only says that health plans are required at a minimum to provide coverage at no cost for certain preventive services recommended by the Preventive Services Task Force. But these are simply the minimum level, not the maximum. The task force will establish the floor of covered preventive services, not the ceiling. No health plan will be prohibited from providing free coverage of a broader range of preventive services, and in many cases the Secretary of Health and Human Services may well require that. That is because our bill gives the Secretary of Health and Human Services the authority to identify additional preventive services that will be part of the essential health benefits offered by health insurers in the exchange. The simple fact is, the Preventive Services Task Force cannot set Federal policy and they cannot deny coverage, period, although there has been a lot of misinformation that has gone out about this. They simply give doctors and patients the best medical information, as I said earlier, not based on cost--cost cannot be a factor--but based on science and based upon efficacy and based upon outcomes and nothing else. Still, I share the concerns of some that the task force has not spent enough time studying preventive services that are unique to women. This is a concern that was raised when the HELP Committee debated the bill in committee. At that time, I worked with the Senator from Maryland, Ms. Mikulski, to include language requiring that all health plans cover comprehensive women's preventive care and screenings based upon guidelines supported by what we call HRSA, the Health Resources and Services Administration, again, with no copays, no deductions. That language is in our bill. It was not included in the merged bill. Senator Mikulski's amendment which is now before us and which I have cosponsored would add that language--would add that language--like we had in our committee bill, and I strongly urge its adoption. By voting for this amendment, which I understand we will do in a couple of hours, we can ensure all women will have access to the same baseline set of comprehensive preventive benefits that Members of Congress and those in the Federal Employees Health Benefits Program currently enjoy. Let me repeat that. If you vote for the Mikulski amendment, you will ensure that all women will have access to the same baseline set of preventive services that are enjoyed by Members of Congress, women Members of Congress, and all women Federal employees in the Federal Employees Health Benefits Plan. That is what voting for the Mikulski amendment will do. Expanding preventive health care is just one of the ways this bill benefits women. Again, our health care system is broken. It is expensive. Today, less than half of women have access to employer- sponsored insurance coverage. Think about that. Less than half of the women in this country have access to employer-based insurance coverage. Again, many of these women work for very small businesses, and they can't afford to provide that kind of insurance coverage. In most States, it is legal for insurance companies to charge women more than men for the same policy. Women can pay more than double what men pay at the same age for the same coverage. Each year, thousands of women are denied coverage from health insurance companies for preexisting conditions. In many States, a history of hospitalizations from domestic violence is considered a preexisting condition. Think about that. A battered woman lives through domestic violence and now can't get health insurance coverage because of a preexisting condition--being battered. That happens in many States. With these options, it is not surprising that more than 16 million women are uninsured in this country. Women are often the health care decisionmakers for their families. They face difficult choices daily. One-third of women are forced to make tradeoffs between basic necessities and health care. In 2009, more than one-half of women reported delaying care because of its high cost. Today, we have the opportunity to fix these problems. This historic legislation now before us increases access to affordable health insurance and ensures that women's coverage meets their health care needs. We will end premium discrimination against women. We will end discrimination against those with preexisting conditions. We will prohibit the rescission of health insurance coverage because of an illness. We will provide more affordable insurance choices through the health insurance exchange, including a strong public option to increase competition and choice. We will ensure that the policies families buy are good enough. We will require that all insurance policies sold in all markets provide adequate coverage for primary and preventive care, for screenings, maternity services, and many other services that women and their families need to stay healthy. As has been said many times before, this bill will extend coverage to an additional 31 million Americans who are currently uninsured. As I said, 16 million women in America are uninsured. So that is why Senator Mikulski's amendment is so important, vitally important. That is why this bill is so vitally important. We are going to talk a lot about Medicare. I see the Republicans are focusing on that, although a recent letter I read and had inserted in the Record from the National Committee to Preserve Social Security and Medicare says we ought to oppose the McCain amendment. We will hear a lot about that. What about the women of this country and what is happening to them? The Mikulski amendment addresses that in a very profound way. But then this bill takes it even a step further by making sure that women, many of whom work for small businesses, who are sort of in an uncovered pool, so to speak, out there by themselves, now they can go on the exchange. Now they can get the kind of coverage they need. They will have choices available to them--not just maybe one option and in some States no option. They will have different options available. They will be able to join with other like women around so they will have a bigger pool and better coverage for themselves and their families. Yes, I can honestly say the health care reform bill before us, the Patient Protection and Affordable Care Act, is a pro-woman bill. It is not talked about a lot, but many of the things in this bill will go to ease the dilemma so many women find themselves in, in this country-- providing basic necessities for their children or trying to get health care coverage for themselves. I can tell you so many women whom I have met and talked to have given up on buying health insurance for themselves so they will have enough money to feed and clothe their kids and send them to school. Women should not be forced to make that kind of a choice. This bill before us will enable women to not have to make that choice. They will be able to get the insurance coverage they need at an affordable price, with the tax credits that are included for low-income women, and they will be able to have the piece of mind of knowing that they and their kids are truly covered with the health insurance they need. I will keep coming back to these two things, time after time, as we go through the bill: prevention and wellness. Keeping people healthy in the first place is a big part of this bill. If there is one thing that will bend the cost curve, it is putting more focus upfront on prevention and more focus on keeping people healthy in the first place. That will save us money in the future. The second theme is what this is going to do for the women of America; how is it going to help them and their families to have peace of mind and to have the health insurance coverage they need. With that, I yield the floor.

Mr. HARKIN

Mr. HARKIN. Mr. President, I thank the Senator from New Jersey for his very strong and poignant statement. I listened to it all. I think he really summed it all up. Let me add to that by saying we are at a momentous crossroads right now in the history of our country. We are at a time that likens itself to 1935, when this Congress passed the Social Security Act. It is like the time in 1965 when Congress passed Medicare. Both of them were giant steps forward in the health and economic security of the American people. But as much as they are part and parcel of our American life today, both Social Security and Medicare were bitterly opposed in this Senate by conservatives who did not want to change. In fact, one conservative Republican Senator said that passing Social Security would put an ``end to the progress of our great country.'' They attacked Medicare as socialized medicine. As Senator Robert Taft said at that time, ``It is going to Sovietize America if we have Medicare. It is going to be a government takeover.'' Well, here they go again. They are unduly frightening people in this country. We saw it earlier with the death panels--all bogus. It was to instill fear in people. It is hard to change, but the people of America voted last November overwhelmingly for Barack Obama and for Democrats in the House and Senate because they wanted to change the system. They knew we had to change. People don't fear change. They know it is tough, but they don't fear it. They don't fear change in our health care system either. What people fear is keeping the present system. That is what I hear. They fear being denied coverage because they have a preexisting condition or one of their children has a preexisting condition and they will not be able to get health care coverage. That is what people fear. They fear they will be dropped from their policy because they have come down with cancer or heart disease or some other chronic illness. They fear that if they have a serious illness, they will have to go into bankruptcy to pay the bills. Sixty-two percent of all the bankruptcies in this country are because of medical causes. Eighty percent of those are people who already had coverage. That is what people really fear. Another reason I think conservative forces will fail this time is because they believe people who have good health insurance really lack compassion and they don't care about the 46 million other Americans who don't have it. I disagree. People care deeply about those 46 million Americans who don't have insurance. It is a national shame when children don't have access to a doctor. It is unfortunate that our Republican friends are determined to prevent us from even debating and amending the bill. That is what the vote tonight is about. Republicans and the health insurance industry are joined at the hip, using the same talking points, same distortions, same cooked-up scare tactics. All I can say is, since the Republicans' goal is to obstruct, obstruct, and obstruct, the people of this country are looking to us, to the Democrats, as they did in Social Security and as they did in Medicare, they are looking to us to move this country forward. So this is a call to arms for our caucus. I hate to put it in those kinds of partisan terms, but what can I do when every single Republican says they want to obstruct and stop this bill? It is now on us, the Democratic caucus, all 60 Members, to come here and stand strong for the American people. Now is not the time to go wobbly in the knees, I say to my friends in the Democratic caucus. Now is the time to stand strong, the time to come to the well at 8 o'clock tonight and move this country forward. It is time to say yes to the American people and no to these fears and unfounded allegations you will hear from the other side. Now is the time to take the next step forward in the real progress of this country.

Mr. HARKIN

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