Bill Nelson

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I do not think there was any person who lives on planet Earth, who saw the clip on CNN this morning of dying children in Haiti, who did not have emotion overwhelm them, as my wife Grace and I, having been to Haiti many times. We saw the fact that children are dying in Haiti because they cannot get medicine and/ or cannot get medical supplies. It is an inexcusable and intolerable situation. If you hear emotion in my voice, you will understand that the Nelson office has been working on this crisis for over the past week since the earthquake hit because we have been talking to our doctors and we have so many of our Florida physicians who are down there doing heroic work. A lot of the work is being done by the University of Miami School of Medicine. A lot of it is being done with the coordinated efforts of Jackson Memorial Hospital in Miami, some of the children's hospitals in Florida. As we have been on the phone with the various agencies trying to cut the redtape so that the supplies can get in or, in the alternative, we can get the critically injured children out, whether it be to a third country, to another part of Haiti, or back to the United States--critically injured--in order to save their lives, we are still having difficulties. Since we are not going to be voting on this debt ceiling raising that would be a critical vote here, I am taking off at 4 o'clock in the morning with a bunch of doctors from a Tampa charity directly into Port-au-Prince, where I will meet with one of the greatest heroes, Dr. Barth Green, one of the lead physicians, a neurosurgeon from the University of Miami and Miami Jackson Memorial Hospital, who has been down there since the day after the earthquake and has been begging for help. What I want to do is cut through some of this redtape. I want to give you an example. Here is the latest plea from Dr. Green: There are 3 critically burned Haitian patients, one in our [University of Miami]/Project Medishare Hospital and 2 on the USNS Comfort-- The naval hospital ship-- that needed to be medevacced to the Ryder Burn Unit tomorrow [morning]. This is an e-mail plea from last night. We need ok from the US Embassy [for patient] #1 or #2 or #3 to authorize the US Military to take on C130 aircraft. Please help save their lives. I need immediate [help] to do the right thing. We are trying to cut through this redtape. If it takes me going down there to try to whack through it myself, that is what I am going to do. Six of us are crowding into a little jet in the morning at 4 a.m., five doctors and me, packed with medical supplies to do that. I know the State Department, the Defense Department, the Department of Homeland Security--we have been talking to all these folks--have been trying. But bureaucracy gets in the way. Let me share with you an e-mail from the State Department. Get this: Thank you for your email. We will provide information about your U.S. citizen constituent to the U.S. Embassy in Port au Prince as quickly as possible. That is a standardized e-mail. That doesn't say anything. It doesn't give specifics. I know they roll these things out, but don't send that kind of e-mail to me to try to placate me because it doesn't. I want action. I want to give another example. Senator Levin is making a plea. He called us when he found out I was going to Haiti. Senator Levin's office has a Haitian who is in Michigan, a dad. He is there legally. He is not a naturalized citizen, but he is there legally. His daughter is critically injured. This is addressed to me, and it is about getting this daughter air-vacced out of Haiti because she has critical injuries. This is from the Department of State. This is a little girl, a 17-year-old with a broken back. She is being denied being put on an aircraft. Mr. Nelson, Due to the fact that Samantha is neither an American citizen nor a U.S. Lawful Permanent Resident, she would be ineligible to board an aircraft to the United States. Currently, all visa operations at the U.S. Embassy in Port au Prince, including immigrant visas, have been suspended until further notice while our Embassy focuses its resources to assisting American citizens in Haiti. This little girl can't board an American aircraft because she has a broken back. She needs to be medevacced so that her life can be saved. We have another child with a collapsed lung. Dr. Green told us about this child. He cannot save that child with a routine procedure to save people with collapsed lungs unless he can get the proper medical attention and maybe they can get him out there onto that hospital ship. But this is the kind of bureaucracy we are running into. The Department of Homeland Security, which handles Customs and Border Patrol--and don't talk to me about people trying to sneak into the States. We live with this problem in Florida. We know what it is trying to make people legal in their immigrations. But the Department of Homeland Security--Customs and Border Patrol is telling me their agents on the ground, when these critically injured children come in, have the authority to give, in essence, what is called a medical waiver for a child who is obviously in extremis, and they assured us that will be the case. Well, I hope so. That is why I have come to the floor of the Senate, because I get these other e-mails and I get these pleas from physicians such as Dr. Green who are saying kids are dying because they can't get them out. We are not talking about a lot. We are talking about 200 whom I know of right now in order to be able to get them out. I will continue to work this problem all the rest of this day, until I get on that aircraft at 4 o'clock in the morning. Then I will work this problem when I get on the ground in Port-au-Prince. It is total chaos down there. The American military, the American civilian agencies, the State Department, the Department of Homeland Security, all the agencies, are making heroic efforts. It is mass chaos because of a critically poor nation that has no infrastructure. When a natural disaster such as this huge earthquake hits, it turns into ultimate chaos. Out of that chaos, we are trying to bring some order. I thank all those souls, American and otherwise, who are contributing to try to bring order out of this chaos. But sometimes we lose sight of the goal because we get so wound up in bureaucracy. That is what we need to get through. That is what I am sure we will get through. At the end of the day, we will find that Haiti will restore itself. Although Haiti's Government is in shambles, Haiti does, in fact, have a President who deeply cares and loves its people. President Preval is clean. You can't say that for all the past leaders of Haiti. I believe President Preval is clean. I don't believe all the people around him are clean, but I think he is. It is time for the industrialized nations of the world to come together and to help these people rebuild. The real crisis is right now, with the dying and the suffering we see in front of our eyes. That has to be attended to. I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I have been listening on C-SPAN 2, in addition to having the privilege of being over here on the floor, to this debate that has been going on. The debate has been going on ever since the summer when we in the committee were fashioning this legislation. I must say that to hear one side of this debate, I would not recognize all of those hearings we had last summer and all the markup we did in the Finance Committee last September because what has been presented to the Senate, and what has been presented to the public through press conferences by the opposition to this bill in most cases simply is not correct. I want to give a couple of examples here this evening. In attacking this, saying what dastardly things this is going to do for the country and how this is going to increase costs and raise taxes--each one of these things can be refuted. But it is a typical tactic that, when you want to attack something and tear it down, you go after a specific item instead in order to obfuscate, which then misses the point of the whole piece of legislation. The point of the whole piece of legislation is to make health care available and affordable, in most cases through health insurance, in other cases through Medicare and Medicaid, and making it available, efficient, and affordable. I want to give one specific example. It is a technical term in the insurance industry called the ``medical loss ratio.'' It is the ratio in what an insurance company actually pays out in medical claims as opposed to what it pays for administrative expenses such as marketing, insurance agent commissions, underwriting, and an insurance company's profit. It is interesting that the term medical loss ratio tells you a lot about the insurance industry, because if you look at it only from their perspective, this percentage is their loss but in fact the percentage is the amount of the premium dollar that goes to actual medical care. What this amendment, this managers' amendment we are going to vote on in less than 2 hours right now says, is it causes a specific ratio so you are getting a high amount of return on the insurance premium dollar. Let me give an example. This is an example of the medical loss ratio of a number of small employers--small employers, that is group policies--as well as policies in the individual market. This is where you have an employer who pays for your health insurance but it is a small employer, usually under 50 employees. This is where you have policies that are given to individuals. The premiums usually are much higher if you are an individual buying insurance than if you are buying it in a group, by an employer- sponsored group. These are specific examples in a particular year of the loss ratio. Interestingly, for Aetna, here, at 82 percent--that is not actually a loss to Aetna. It is interesting they call it a loss. That is actually 82 cents of premium dollar, an insured policyholder's premium dollar, that actually goes to medical coverage. That is good. United Health: 79; Humana, down at 77--77 cents of that $1 are going to health care. And the balance, 23 cents, is going to things such as administrative expenses, paying for insurance agents, commissions, paying for their profit. What does the bill do? The bill brings that up to 80 percent. And that is all policies, not just the new policies on the health insurance exchange. That is not just the policies insurance companies are going to write new for the small group. It is all those policies that are in existence. Look at the individual. The experience isn't quite as good. As a matter of fact, here is a company, Coventry, that was only paying 66 cents on every premium dollar that was actually going to health care, and the rest of that, 34 cents, was going to profit and administrative expenses and executive salaries and bonuses and so forth. And lo and behold, what we are going to vote on tonight in less than 2 hours is going to have to be 80 cents on every dollar. If they don't make that 80 cents on every dollar, they are going to get penalized. We are putting some real teeth in this on insurance companies for the first time. Look at the large group, the employer-sponsored insurance, the large group. These are five of the larger insurance companies. You can see they have a pretty good record thus far: WellPoint, 85, Humana, 82 cents on every dollar. They have a better record because they have a lot more individual lives over which they can spread the insurance risk, and so they can pay out more in health insurance for health care and take out less for administrative expenses. But in this bill tonight, in an hour and 45 minutes, we are going to raise that to 85 percent, 85 cents on every dollar. Before I came to the Senate--and I have had the good fortune of serving the public for now going on over 35 years--I had the privilege of being elected to one of the toughest jobs I have ever had in a lifetime of public service, and that was the elected insurance commissioner of Florida. It is also the elected treasurer. That position has morphed into what is called the chief financial officer. It is a member of the Florida cabinet. For 6 years, I got to see what insurance companies will do. I can tell you, instead of 85 percent and 80 percent that we are going to require in this bill of every insurance premium dollar they pay out in medical care, I can tell you that some of the insurance companies I regulated back in the State of Florida were down in the sixties. A lot of that was going into big-time administrative offices, all kinds of jets, all kinds of padded expense accounts. You can see what we are trying to do here with this bill tonight. Let's ask, why do we have to have a ratio such as this and why is it important? It certainly is getting more medical care to the individual policyholder. But listen to this: A study that was done by the Senate Commerce Committee shows that the ratios are often below what is considered to be fair. Our Commerce Committee found that in the small business market, those with fewer than 50 employees, insurers spend only 79 cents out of every dollar on health care. That is in the Commerce Committee study. In the individual market, it is even worse. It is 74 cents. In the individual market, the insurer keeps more than a quarter of every individual premium dollar for overhead and profit. We need to ensure that the policyholder's premiums and the Federal subsidies that are going into the purchase of private health insurance on the exchange are used for actual medical care and not for wasteful administrative spending and marketing and profits. If we don't do this kind of thing, regulating insurance companies, then they are going to take advantage. They are going to take the advantage of making more money at the expense of patient care. I want to give an example. In spite of this recession, this economic recession we are in and the increasing unemployment over the past year, what has happened to the big insurance companies? They are posting big profits. They seem to be making more money by insuring fewer people. The only way you make more money with fewer customers is you get rid of your less profitable customers--in other words, the sick ones. That is called cherry-picking. You pick the good risks, which are the healthy ones, and you try to get rid of the sick ones. Let me give some examples. In the second quarter of this year, 2009, the largest health insurance company, UnitedHealth Group, announced a 3-month profit of $859 million in one quarter, and it more than doubled the profits from the previous year. UnitedHealth earned these record profits in spite of the fact that it was insuring 600,000 fewer people than it did a year ago. Let me give another example. In the second quarter of this year, another large insurer, CIGNA, saw its profits jump 60 percent to $435 million. CIGNA earned these healthy profits in spite of the fact that it is insuring 200,000 fewer people than a year ago. Another example: In the second quarter of 2009, Humana saw its profits rise 34 percent to $282 million. Humana earned those healthy profits in spite of the fact that it was insuring 100,000 fewer people than a year ago. At the same time they are dropping beneficiaries, insurance companies are paying their CEOs record salaries. In 2008, Aetna's CEO earned over $24 million. That is the equivalent of more than $66,000 per day. If you want to know where some of that administrative padding that is not coming back to the policyholder in health care is going, there is a good example. Aetna's CEO earned over $24 million in that 1 year, 2008. This medical loss ratio we are building into this bill on which we will vote shortly builds on other insurance provisions in this legislation which include guaranteed issue, which include prohibiting cancellations, banning preexisting conditions so that they can't terminate you or not insure you because they cook up some excuse, some flimsy excuse. I am not sure this has been brought out in this debate, but I think it is worthy of consideration by the Senate. In my closing minutes, I want to now step back and look at the overall package. Why is this a good deal for America, and why is it going to pass with an extraordinary threshold of 60 votes tonight? Because we are not going to allow in this legislation excessive rate increases in the health insurance exchange that is created new, that is going to insure 31 million new people. A lot of those people are people who don't have insurance now. A company will be banned from that health insurance exchange if it starts jacking up its rates excessively. You talk about an insurance commissioner's dream, a regulator's dream-- often your hands are tied and you are put into a straitjacket by the insurance laws of your State and you can't crack the whip on them. We are cracking the whip on them in this legislation. There has been a lot of talk about the program on Medicare other than Medicare fee-for-service called Medicare Advantage and how it is going to be whacked. I can tell you, for my State of Florida, there are 950,000 senior citizens on Medicare Advantage, and it is not going to be whacked. There have been a lot of statements out here by people attributing it to Florida, that it was going to be cut. In this bill we are voting on tonight and whenever we go to final passage, it is not. By the way, there was a statement made here and something that was entered into the Record, a letter from a cardiologist from Jupiter, FL, who was complaining about how cardiologists' fees are being squeezed and they may not be able in the future to take care of Medicare recipients. I happen to know about this. I have been trying to help the cardiologists. But it was stated out here on the floor of the Senate that it is this bill that is doing that. That has nothing to do with this legislation. That has to do with the administrative functions of government in existing law, CMS, that, in my opinion, has used incomplete data to cut cardiologists, particularly that are needed in a State such as Florida where, in fact, so many senior citizens are needing the service in Medicare of cardiologists. Here is another major thing in this bill. We are setting up a nationwide insurance plan that will be sold on these health insurance exchanges, and it will be operated by the Office of Personnel Management, the same office that governs the health insurance of Federal employees and Members of Congress. There is a part in this bill on tort reform. It sets up State grants to test alternatives to litigation. In my remaining minute, let's don't forget the 31 million more people who are going to come in insured and how this, over time, is going to bring down the cost of Medicare. It is not going to cut Medicare. It is going to save Medicare. It is going to do that with efficiencies such as electronic records and accountable care organizations and emphasis on primary care physicians. To conclude, what else does the bill do? It lowers the deficit over the next 10 years by $132 billion. In the second 10-year period, it is going to lower it by up to $1.3 trillion. That is serious deficit reduction. On that happy note, I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, is it any wonder that people are responding negatively when asked, Do you support health care, when they have been bombarded with millions of dollars of TV advertisements that are not telling what this health care bill does? Is it any wonder when they hear comments such as this health care bill will not save the American consuming public on their health insurance premiums? What does it do? Can you believe that it is not going to allow insurance companies to cancel your policies? Can you believe that it is not going to let an insurance company come up with some kind of fictitious excuse that you have had a skin rash and, therefore, you have a preexisting condition and they are not going to insure you? Can you believe that it is going to bring in 3l million new people who are going to have health insurance who did not have health insurance before, and that all the rest of us paid for when they showed up at the emergency room? Can you believe that this health care bill is going to bring down the cost of Medicare over the course of time and is going to save Medicare instead of Medicare running out of funds in about 6 or 7 years? Can you believe that by creating a health insurance exchange for the private marketplace for private health insurance companies to compete for that available exchange of people who want to buy health insurance there, it is going to bring down their health insurance premiums from what they would otherwise pay? You probably say it is hard for me to believe that because of all the negative I have heard. But that is exactly what the experts tell us this bill is going to do. And, oh, by the way, it is going to do one more thing. Over 10 years, this bill is going to reduce the deficit by $130 billion. Can you believe that? Not if you have been listening to all the stuff that has been thrown around about how bad the bill is. But that is the tactic. That is the tactic of ``in your face,'' ``oh, ain't it awful.'' It is time the real story gets out. You know what will happen? When this bill is passed and it is finally signed into law by the President, then the real story is going to get out and people will know. In the meantime, I wish that in the Senate we could have closed the doughnut hole. The doughnut hole is the gap in coverage for Medicare recipients where they have to continue to pay premiums for Medicare but they receive no drug coverage whatsoever. Under current law, a Medicare beneficiary will pay up to $310 for their drugs, which is the deductible, and then they pay 25 percent of their drugs up until they have paid out a total out of their pocket of $940. Above that, they hit the dread doughnut hole and they continue to pay premiums, but they receive no help from Medicare for their drugs all the way up to a much higher level. There are 3.5 million people who hit that dread doughnut hole. Each year, because of the formulas, the doughnut hole grows bigger and it is compounded by higher and rising drug prices. We have seen that the pharmaceutical industry has raised their prices 9 percent. These out-of-control increases in prescription costs are hurting our folks and especially seniors on fixed incomes. It is no secret that I wanted to fill the doughnut hole. It is not going to happen. But what is going to happen when this gets into conference with the House of Representatives--in fact, there has been a commitment by the majority leader, there has been a commitment and a statement by AARP, which has a significant interest in this legislation, there was a pledge on this floor by Senators Reid, Baucus, and Dodd to close the doughnut hole. I suspect that what has happened is, they have gotten the agreement of the pharmaceutical industry to help them close that doughnut hole once we get into the conference committee with the House of Representatives. But first, we have to get the bill out of here. That means we have to stand up and push back all of this nonsense and misinformation that is coming about this bill. What does it do, to recapitulate. It lowers the cost of Medicare over time. It gives a reduction of the Federal deficit. It allows insurance for people who do not have it to be available and affordable and they cannot cancel or use some flimsy excuse to cancel. It will utilize the private marketplace in which to make this happen. This is an American story, and it is going to be an American success story. Mr. President, I yield the floor. I suggest the absence of a quorum.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, it is a wonder this health care bill has survived this far with so many people shooting at it. But survive it must and survive it will, because it is the right thing to do. With a country that has 46 million people who do not have health insurance, when they do get health care, it costs the rest of us a lot of money because they get it free in the most expensive place. That is not a system that is operating as it should and that is what this whole effort is about. This whole effort is about trying to help people who cannot get insurance get it--those who desperately want it, who cannot get it, to be able to get it--and those who have it to not have it canceled on them in the middle of their treatments. It is all about people who desperately want insurance suddenly having an excuse from an insurance company: No, you can't get insurance because you have a preexisting condition. Some of those preexisting conditions are the flimsiest excuses. But what about those who have had a heart attack who definitely desperately need health insurance after that? This legislation is all about folks who desperately want insurance and they finally find an insurance company that will insure them and then they cannot afford it. Why, in America, in the year 2009 and almost 2010, aren't we at the point of being able to give our people the confidence, the satisfaction, the loss of fright that they cannot take care of their families if they get sick? That is what this legislation is all about. But everybody and his brother and sister are taking these potshots and every special interest that has their finger in the pie wants their share of the pie and to heck with anybody else. This is what we are trying to overcome. We are trying to overcome a system that has built up since World War II, over the last 60 years, that is inefficient and is not giving the health care to the people who desperately need it, unless they can afford it. So despite all these potshots, survive this bill, it must and survive it will. We are going to pass this bill, and somehow we are going to get 60 votes cobbled together to break this filibuster so we can get on to the final passage of this legislation. I wish to give one example. You remember that story, that famous novel, ``A Tale of Two Cities,'' about London and Paris? I am going to give you a story, a tale of two industries and what they are doing in this bill. One industry is the insurance industry, the other industry is the pharmaceutical industry--two industries that have an enormous interest in the outcome and high stakes in how this legislation comes out. On the one hand is the insurance industry. They are running TV ads all over this country, trying to torpedo this. If you watch those 30- second and 60-second ads, you would think this is the worst thing that is going to bankrupt America, and we are not going to have anybody given any insurance. Why are they doing this? Because they know they are going to have to suddenly act responsibly. They are not going to be able to have the excuse of a preexisting condition, they are not going to be able to cancel your policy in the middle of your treatment. You thought they would come to the table, when suddenly we were going to insure an additional 46 million people, that they were going to get all those premiums. But because the subsidies were not enough for the poor people or, if they did not buy that insurance in the health insurance exchange that the penalty wasn't enough, the insurance industry said: Forget it. Contrast that with the pharmaceutical industry. The pharmaceutical industry, to their credit, is still supporting this bill. That is very good. They are one of the few deep-pocketed industries that can go out and buy TV time and support this bill. But remember when I said everybody has their finger in the pie? The pharmaceutical industry--I want them to know how much I appreciate what they have done, but they can do more. Let me give a case in point. They say in their so-called $80 billion contribution that $20 billion of that is to have a 50- percent discount on their brand-named drugs in the doughnut hole. The doughnut hole is that vast amount--of about $3,000 that senior citizens, once Medicare helps them get up to it--it is about $2,300-- above that all the way up to about $5,300 the Medicare recipient doesn't get any reimbursement. It is not until that higher level that catastrophic Medicare coverage kicks in. What the pharmaceutical industry has said is they will come in and give a 50-percent discount. Of their $80 billion contribution, that is worth $20 billion. But here is what they didn't tell you. Again, I am speaking very favorably for them because they are supporting the legislation. But this is what they did not tell you. They did not tell you, with that 50-percent discount, that, No. 1, they are going to have increased sales of their brand-name drugs to the tune of $5 billion over this 10-year period in the doughnut hole because they are selling more drugs in the doughnut hole; and because that means more people get above that $5,300 level and get it into catastrophic coverage, that they are going to be able to sell, incremental sales, another $25 billion or a total of increased sales of $30 billion. They are going to contribute $20 billion, but they are going to get $30 billion additional. So they come out a net $10 billion over 10 years to the good. What I would ask the pharmaceutical industry--that we appreciate--to do is come in and give a 100-percent discount and, by their open numbers, they have come up with, in a study by Morgan Stanley--by their own numbers, a 100-percent discount would cost them $40 billion over 10 years, but they would reap back, by Morgan Stanley's numbers, $60 billion. They would be, the pharmaceutical industry would be $20 billion to the good. It is a tale of two industries. One is the insurance industry, which grabbed its bag of marbles and said you are not making the penalties severe enough, we are taking our bag of marbles and we are going home and we are going to try to defeat your bill. No. 2, the pharmaceutical industry, which has still hung in there but which can do a lot more. I hope, as we get into these negotiations, they will be willing to step up and set the example of health care reform in America. I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Madam President, I ask unanimous consent to speak as in morning business.

Mr. NELSON of Florida. Madam President, we have in front of us appropriations bills. We have heavy matters of the deficit. We have heavy matters of how we are going to get the U.S. Government to get its fiscal house in order. I remind the Senate the last time we had a surplus was in 2001. If we had been wise and had not cut the revenue of this country so significantly, we could have been good stewards of that healthy surplus and we could have paid off the national debt over a 12-year period, and we wouldn't be where we are today, but we are. While these matters are weighing heavily on us, it seems our attention is being continuously diverted to other things, such as White House party crashers and the unfortunate circumstance that one of the most famous athletes, Tiger Woods, finds himself in. We have a debate about the health care bill and it seems that during the course of last summer, the whole health care debate was about one subject and that was the question of the public option. We now know, because all the experts are telling us, that if we have a public option as a part of this health insurance exchange, the exchange itself will only cover something like 15 to 20 percent max of the people, and the public option would only include something like 4 million or 5 million people, and that we are talking about 1.5 percent of the total folks in the country. Yet the debate raged all summer as if that were the only issue about health reform. So here we find ourselves trying to pass a health reform bill with so much attention diverted elsewhere, with people pushing and pulling and tugging--all the special interests--how in the world can we bring this together? How do we bring it together so we can get the high threshold of 60 votes in the Senate? On the one hand, there are the insurance companies. The insurance companies have a huge stake. Now the insurance companies are running TV advertisements all over the country trying to kill this bill because they realize there is going to be a limitation on their ability to do everything they want to do and to charge what they want to charge and to cancel at will, and to have frivolous reasons such as a skin rash as a preexisting condition and therefore we are not going to insure you. That is what has led to us getting to the point of saying, ``Enough. We are going to pass a health insurance reform bill.'' Then, of course, what comes to light is suddenly, in this package that was not in the package that came out of the Senate Finance Committee but is in this package, there is actually a nod to the insurance industry in the form of a limitation on the amount of payments that could be made on anyone's insurance policy in one year. Well, again, there is a lot of opportunity for mischief and abuse. We have to correct things such as that. Is there anyone who doubts that we don't need health insurance reform and health care reform, even though we are getting the opposite messages from the insurance companies; that we are getting the opposite messages from anybody who is a special interest that doesn't get entirely what they want? What are some of those? Hospitals, doctors, all kinds of health providers, medical device manufacturers, and the various interests of patients. But if you look at it, you can't get all that you want, Mr. Special Interest, and instead, keep in mind the goal we are trying to achieve, and that is take a system that is near tilt and get it on the road to reform. There is another part of this reform we have to do and that is that the U.S. Government cannot afford the cost escalation that is going on in its payment of Medicare and Medicaid. So there are reforms we can enact, many of which are in this bill, such as accountable care organizations that will follow the patient; electronic records that will modernize records so that any doctor or health care provider who sees the patient will have up-to-date access to what has been the care so that records are not lost; emphasis on a primary care physician who can do a lot of preventive care before the emergency ever gets there; then, of course, utilizing a lot of the miracles of modern medicine including pharmaceuticals to hold off conditions so that we don't get to that emergency; so that if you are not insured you end up at the emergency room, or even if you are insured you end up at the emergency room, which is the most expensive place to get care. Is there a lot we can do? Yes. It is what we must do. With the hurdle in this Senate being so high that we have to get 60 votes to close off debate, we have to be successful. It will not be pretty and it will not be perfect, but it will be a step in the right direction. There are portions of this proposed law that will take effect not immediately but a year or two or three down the road, and if we have made mistakes, we can correct those mistakes, but we must be successful. For us to turn back now, no matter who is arguing against it, for us to protect a special interest, no matter who is arguing for it, at the expense of the greater good of health care reform, would be a drastic mistake. Not one of us will be happy going home to our families for Christmas if we don't enact this. It is for those reasons that I feel very strongly we will be successful, as difficult and as tortuous as this process is. This Senator will keep pressing forward until we get that final passage. Madam President, I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I ask unanimous consent that the time for debate only be extended until 2 p.m., with the time equally divided, with Senators permitted to speak for up to 10 minutes each, with no amendments in order during this time.

Mr. NELSON of Florida. It is back and forth.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I am back on the floor on this, as I have been over the course of the last decade, because we have been like a yo-yo in my State of Florida on the importation of drugs, since we have quite a few senior citizens in our State. They have been accustomed to either going to Canada and bringing back prescriptions at half the price or phoning Canada to pharmacies and having those drugs shipped in the Postal Service or e-mailing to Canadian pharmacies. What happened over the course of the last 8 or 9 years is that the previous administration cracked down on the reimportation of these drugs. Of course, that was at a great expense to our senior citizens who can buy these drugs at roughly \1/2\ of what they pay by going into the pharmacies in the United States. Then an interesting thing happened along about 2006. This Senator started getting multiples of calls--I think up to something like 100 complaints in that 1 year from senior citizens who had purchased the drugs, either by e-mail, telephone, or by going personally there and having them shipped. And lo and behold, under the previous administration, they gave the order to the Postal Service to confiscate these drugs. This happened, for example, to a couple from Mt. Dora, FL, Mr. and Mrs. Lee Eads. They had their drugs confiscated. We went after the Postal Service. We went after the Customs Bureau. We found, in fact, that a lot of these complaints we had received, those drugs had been confiscated when, in fact, the policy was supposed to be if it was pharmaceuticals for personal use--and they defined that as less than a 90-day supply--the government, the U.S. Government, was going to let these senior citizens take advantage of getting that cost break of a 50-percent reduction. It took us till late 2006--getting into this with Mr. and Mrs. Eads as the poster couple who had been getting their prescription drugs and then, all of a sudden, they were confiscated--to get the Postal Service and Customs to reverse. This has supposedly been the policy, but we can't get it etched into law because people keep bringing up this Trojan horse that it is not safe. The very manufacturers we are buying our prescriptions from here in American pharmacies are the same manufacturers in identical locations with identical labeling of the drugs that are going to Canadian pharmacies. Why can't we give our senior citizens a break? Of course, what this Senator would like to do is to give them a bigger break. This Senator has an amendment, which is continuously being stated that I may not get to offer, that would cause the pharmaceutical industry to give discounts on the drugs sold under Medicare that are being sold to 6 million people who are eligible because of their low income for Medicaid but get their drugs through Medicare. Those 6 million people, Medicaid, poor people who are eligible to get government assistance, used to have a discount, a substantial discount. Therefore, the U.S. Government was paying less for the drugs it bought for those people. But 6 years ago, when the prescription drug benefit was passed, those 6 million people were suddenly made ineligible to get the drug discount because they were now getting their drugs under Medicare. That is absolutely ridiculous, that the U.S. Government is going to pay full price for the drugs now that they used to pay only a fraction. How much is that worth? According to CBO and the amendment I offered in the Finance Committee that was defeated 10 to 13, that is worth $106 billion over 10 years that would be savings to the American taxpayer that we would be paying for those dual eligibles, Medicaid recipients who get their drugs in Medicare, $106 billion of savings that the U.S. Government would not have to pay for those drugs, if we followed the same policy we did back there before this prescription drug benefit for Medicare. That kind of makes common sense, doesn't it, that we would want to save the American taxpayer $106 billion? But we were defeated by a vote of 13 opposed to the amendment and 10 in favor in the Finance Committee. I know it is a tall order to bring this amendment out here on the floor and have to meet a 60-vote threshold, because 41 Senators can deny the American taxpayer from getting $106 billion of savings. One of the good things about our bill that has come to the floor is, we are going to reduce the deficit by $130 billion. That is over a 10-year period. That is a good thing. But if we would accept my amendment, we could reduce the deficit by $236 billion or we could use part of it-- say, half--to fill the rest of the doughnut hole that the AARP would like and so would this Senator. The AARP strongly supports my amendment. They have made it clear to the leadership of this Senate that they want to see that doughnut hole closed. But there is nothing coming out here on the floor that is going to do that. The amendment Senator Dorgan has offered, which in and of itself is good policy, reimporting drugs at half the cost from Canada, is a step in the right direction, but that doesn't close the doughnut hole. So here we are at a decision point. Who are we going to serve? Let me say at the outset I understand the political dynamics. I want to give credit where credit is due. The pharmaceutical industry is, in fact, supporting the leadership in trying to pass this bill. That is a good thing. We appreciate that very much. We need their support because we have all these other interest groups that are flaking off. At the end of the day, we have to get 60 votes in order to pass health care reform. That includes health insurance reform. We have the insurance industry totally, flat out trying to kill this legislation. I am grateful to the pharmaceutical industry for trying to help us. Therefore, my plea is, there has to be a balance. There has to be a compromise in the works. There has to be a way of the pharmaceutical industry stepping to the plate to help us totally fill the doughnut hole, that gaping $3,000 hole seniors have to pay for all of the drugs they need when they reach that level. There has to be a sweet spot, a compromise. I certainly support the Dorgan amendment. I hope the Senate will favorably consider my amendment later on. I yield the floor. The PRESIDING OFFICER (Mr. Burris.) The Senator from Texas.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I wish to speak on the bill and, in part, respond to the minority leader. At the end of the day, why are we staying around the clock discussing this bill with the intent that we are going to pass the bill? It is simply that we cannot continue as we are. We are in a system whereby insurance is not solving the Nation's health needs. All you have to do is talk to a doctor. If they haven't already pulled their hair out, they are about to, in that when they want to give a certain treatment to a patient, they feel like they have to negotiate with the insurance company. In fact, the insurance company often is dictating to them what treatment and what drugs they can or cannot use or look at the simple little cases we hear about. They are absolutely simple cases but end up with catastrophic results because someone is in the middle of a treatment for something and then they get a notice that their insurance company is going to cancel them or, perhaps, they have lost their job and they are desperately trying to get health insurance again and an insurance company uses, as an excuse, that they had a preexisting condition. It may be a flimsy excuse. I gave the example yesterday of a reason for denial being something as silly as a skin rash as a preexisting condition and so they can't get health insurance now on their own. We have a system that is out of control. We hear a lot about cost out here. We hear a lot about cost. Indeed, if we don't do something about the cost of health care, none of our people are going to be able to afford it. Talk to corporate America and the CEOs and listen to them as they describe what the insurance companies are saying to them and how they are jacking up their rates on their employer-sponsored group policies. Please, pray that you are not an individual who can't get a group policy and you are having to go out there and try to find an individual policy because the likelihood is you are not going to be able to afford it. So cost is a critical factor. It is a factor also to the Government because the U.S. Government cannot afford the cost of Medicare as it keeps exploding into the future. We have to bring these costs under control. When you mix that in with the horror stories that we hear of the 46 million people who don't have health insurance but who, when they get sick, end up in the emergency room, we know they are getting that care at the most expensive place while the rest of us pay. That is a hidden tax. On average, in this Nation, that hidden tax is $1,000 per family's health insurance policy. I can tell you, in my State of Florida it is even higher. It is $1,400. In Florida, a family with a group insurance policy is paying $1,400 more per year to take care of those folks who do not have insurance but end up getting sick, and that bill is paid by everybody else. What I have described is a system that is in tilt. It is not working. The whole purpose of this bill is to try to make it work so, No. 1, it is affordable; No. 2, that health insurance is available. At the end of the day, we are going to pass it. At the end of the day, poor old Harry Reid, our majority leader, is going to figure out a way to get 60 of us to come down here to shut off the filibuster so we can go to final passage and get it down to a conference committee in the House. At the end of the day, after that conference committee comes back, we are going to get those 60 votes again because this is so desperately needed, despite all the supposed arguments we hear from the other side. Can this product be improved? Of course it can. I certainly wish to share, as I did in the Finance Committee, an amendment that would cause the pharmaceutical industry to come up with some more money. They have made a pledge, to their credit. Let me just say that Billy Tauzin, the head of the pharmaceutical association, is smart. He knows what he is doing, and he is trying to play ball with the leadership and the White House. I want the pharmaceutical industry to know this Senator appreciates that because with everybody else, such as the insurance industry, trying to kill it deader than a doornail, at least they are helping. But the pharmaceutical industry said they were coming forth with $80 billion over 10 years that they were going to contribute. The hospital industry said they were going to contribute about $150 billion over 10 years, and so forth. But, in fact, the pharmaceutical industry is not contributing $80 billion. Here is a Morgan Stanley analysis for investors of pharmaceutical stocks. This is their analysis of what is going to happen to the pharmaceutical industry in the future. Morgan Stanley has said these guys are so smart, they are not contributing $80 billion. They are contributing only $22 billion. Why? Because when they say they are going to contribute discounts to allow half of this so-called doughnut hole to be filled, that means there is going to be a lot more drugs sold. Oh, by the way, the bill takes Medicaid from 100 percent to 133 percent. That is going to mean a lot more drugs sold as a result of this bill. So the real loss, or contribution, if you will, of the pharmaceutical industry is $22 billion over 10 years, not $80 billion. That does not even include--remember, they just raised their prices 9 percent, three times the rate of inflation. So they are going to make up a lot of that anyway. What I want to plead with the leadership in the White House and the leadership of the pharmaceutical industry--come back to your $80 billion real figure over 10 years. One way to get there is the amendment I offered in the Finance Committee that was rejected on a narrow vote of 13 to 10. Out here on the floor it is my intention to offer that amendment. I filed it. It would produce, according to the CBO, $106 billion of taxpayer fund savings over 10 years because the discounts would have to be there for the Medicaid recipients who are entitled to discounts, but now, since they buy their drugs through Medicare, they can't get those discounts. That is because we changed the law 6 years ago in the prescription drug benefit. That is just simply not right. I am not out here to try to punish anybody. I am out here to try to make this work and to get 60 votes so we can go to final passage. But everybody has to do their part. Everybody has to contribute for their part. I look forward to the future discussions as we close in on what probably is going to end up being the final passage of this, probably a week or 8 days down the road.

Mr. NELSON of Florida

Mr. NELSON of Florida. When you try to reform the health care system, look who is trying to kill the reform. Thank you, Mr. President.

Mr. NELSON of Florida. Mr. President, the Senator from Florida has 4 minutes?

Mr. NELSON of Florida. Well, let me say, the people of Florida gave me one of the toughest jobs I ever had in my life when they elected me the insurance commissioner 16 years ago of the State of Florida. I have some familiarity with the conduct of the insurance companies, and it does not surprise me that the insurance industry is out to kill this legislation and is spending millions of dollars running TV ads. It does not surprise me that the insurance industry was very interested in this legislation to begin with, when we were going to expand all of those 46 million people who do not have insurance, to bring them into private insurance. It does not surprise me that since they have calculated they have to do their part, and that this bill will not allow them to cancel policies in the middle of somebody getting their health care--and we have heard those horror stories: in the middle of chemotherapy, suddenly, the woman gets the notice that her insurance is canceled. We have heard those horror stories of that little boy who was a year old and was heavy in pounds, and the insurance company said: We are not going to cover him. We hear the stories that: Oh, no, we can't insure you because you have a preexisting condition. And when you look what that preexisting condition is, it was a skin rash. Did you ever hear of the word cherry-picking? That is the typical modus operandi of insurance companies that want to keep their profit. They cherry-pick the good risk, the healthy ones, and they deny insurance to the ones who need the health insurance. So as we come to consider the amendment of the Senator from Arkansas, which I support, as we, many times, come to hear all of this extraneous argument, come right back to the main function. When you try to--

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I want to take this time to talk about this terrible economic recession. To those people, by the way, who do not have a job, it is not a recession, it is a depression. The times are difficult economically all over this country but especially in my State of Florida which has an unemployment rate that is well above the national average, and there are pockets in Florida where the unemployment rate is exceptionally soaring, such as southwest Florida. It is this continued economic devastation from home foreclosures, business closings, and high unemployment rates that is threatening the prosperity of the country and particularly States such as mine, Florida. For example, in southwest Florida, we learned last week that another local bank had been shut down by Federal regulators. It is the sixth bank failure to hit that region this year. On the housing front, numbers were released that indicate Fort Myers still has a long way to go to climb out of the housing mess. While the positive news was that foreclosures had declined 20 percent from September to October, the area still ranks fifth in the country in foreclosures. We need to continue the steps to get the housing market back on its feet. One of those steps we did included the $8,000 tax credit for first-time home buyers. That goes through next spring. Most recently, we took one step further when we passed a $6,500 tax credit for existing homeowners who sell their home and want to buy another. That has spurred home sales. We need to stabilize the prices, which remains the top priority. We also need to keep the pressure on the banks, the lenders, to work with folks who are losing their homes. Many places across the Nation, and specifically Florida, are responding to the crisis by adopting mandatory mediation as an alternative to foreclosures, thereby forcing banks to modify mortgages and avoid a foreclosure altogether. A great success story is a program in Philadelphia where borrowers can keep their homes in a program that is being looked upon as a model for the rest of the Nation. Under a plan put in place by the city's civil court, no property can be foreclosed in that court and sold by the sheriff until the mortgage company sits down with the homeowner to try to find a solution. Unlike the administration's effort to stem foreclosures, which relies on giving incentives to mortgage companies to encourage them to work with homeowners--a program that has not worked as the Obama administration has intended--the Philadelphia program, in contrast, is not a voluntary program. Mortgage companies are forced to participate. While that Philadelphia program will not result in every troubled homeowner getting the outcome they are looking for, making those lenders come to the table is a step in the right direction. But if we are going to bring back health to our banking and financial system, we are going to have to fix the problems that are driving our community and regional banks to insolvency. The crisis in residential and commercial real estate values, home foreclosures, and nonperforming commercial real estate loans is wiping out those regional and local bank balance sheets. In response, those regional banks are desperately hanging on to their deposits and other assets. I wish I didn't have to say this, but the Obama administration, particularly Secretary Geithner, has not done a good job in leading our banking system and real estate markets to recover. Their response to the collapse in residential real estate was a tepid loan modification program which in most cases kicked the can down the road for the few underwater homeowners who were fortunate enough to qualify. Their response to the crisis in commercial real estate has been absent altogether. The consequence is that the commercial real estate market is on the verge of its own collapse as creditors are reluctant to refinance commercial projects. Half way through the year, Florida banks had over $5 billion of commercial real estate loans in default. Commercial real estate makes up over one-third of the assets of Florida banks. These growing liabilities are putting the brakes on bank lending in Florida, and they are hurting creditworthy small businesses and prospective home buyers. It is a vicious downward spiral that is not easily broken. One thing is clear: The Troubled Asset Relief Program has not been the answer. When then-Secretary of the Treasury Hank Paulson, the former head of Goldman Sachs, first proposed TARP, there were a number of us on this floor who opposed and voted against it. I thought it was massive and a wasteful bailout of the Wall Street banks with zero accountability and no meaningful reform. What have we found out about it? Of the $700 billion that Congress appropriated for TARP, over $220 billion has yet to be loaned out and only some $70 billion has been repaid. I believe we should end the program once and for all and return those funds to the U.S. Treasury to prevent us from falling deeper into fiscal debt and a fiscal black hole. Bringing the deficit under control would then help stabilize interest rates. It would hold borrowing costs down, and it would reduce the growing debt burden on future generations. That still leaves roughly $400 billion of TARP funds outstanding. Bank of America, Citigroup, and Wells Fargo need to repay the TARP funds that have propped them up for more than a year. They need to stand on their own feet. Banks such as Goldman Sachs that have repaid their TARP funds still owe a tremendous debt to American taxpayers. Goldman Sachs, Merrill Lynch, and a slew of other banks all profited from the dollar-for-dollar taxpayer bailout of AIG's credit default swaps, those insurance policies. Under that AIG bailout, the most outrageous of all the bailouts, $70 billion of American taxpayer funds was put at risk to ensure that speculators in credit default swaps were fully protected. The head of Goldman Sachs recently apologized for his firm's reckless behavior and pledged to commit $500 million for small business lending. That sounds like a serious commitment, until we consider that Goldman Sachs has set aside $17 billion for year-end bonuses. So while Main Street is tightening its belt and preparing for a lean holiday season, Wall Street is still living high on the hog. That must change. As banks repay their TARP loans, we need to consider how we use those funds, how we reform the financial sector. To get us back on track, we will have to be creative and find new solutions to ensure that businesses have access to the capital they need to grow, prosper, and hire new workers. I have a few suggestions. First, we need to scrap the trickle-down TARP model and start working from the bottom up. We need to focus on access to capital for small businesses and ways to shore up residential and commercial real estate values. TARP has focused far too much on the largest Wall Street banks at the expense of community and regional banks, the backbone of finance in Florida. We need to increase Federal support and assistance to community banks and credit unions. Second, we need to look at other ways to improve access to capital such as promoting direct lending by the Small Business Administration. Third, we need a flexible approach to dealing with underwater homeowners, those whose value is now less than the value of their mortgage, which is so typical in the State of Florida. A flexible approach would be like the one in Philadelphia which is undertaking to require mediation and loan modifications. These are a few suggestions I have in this very tough economic time. I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, when we start the debate on the health bill, I will be exceptionally eager to take the floor and to address some of the points the Republican leader has just addressed. Most of us went home. As the minority leader said, most of us heard from our constituents who were not bashful about expressing their opinions. It is interesting that a lot of those opinions I heard were from the people who are just reeling in agony because they are in the middle of some medical procedure such as chemotherapy and suddenly they get a notice from their insurance company that they are canceled or they are desperate to get health insurance coverage and have been terminated from their job where they had it, and then an insurance company tells them they will will not insure them because they have a preexisting condition. I do not believe there is anybody in America who is satisfied with the way the overall health care and health insurance industry delivery system is giving us our health care. Whenever it is said this bill that is before the Senate now is going to increase the cost, let's remember our costs are already increased by the people who do not have insurance who end up at the most expensive place, which is the emergency room, since they have not had any preventive care when they are in an emergency. All of the rest of us pay for it. On average that is $900 to $1,000 that is tacked on to our insurance policies we are paying as a hidden tax to pay for all those whom, if brought into the health insurance system, we would not be paying for. I will save the rest of my remarks until we get on the health bill.

Mr. NELSON of Florida

Mr. NELSON of Florida. I ask unanimous consent that I be able to proceed for 2 minutes.

Mr. NELSON of Florida. I will vote for the motion to proceed to bring the legislation before the Senate. This is a debate we must have. It is a debate we cannot afford not to have. What is before us is to make health insurance available and affordable. The legislation that will come before us will prevent someone from being denied insurance because they have a preexisting condition. It will not allow the insurance companies to cancel policies because someone is sick. It will bring in millions of uninsured people who will then be able to have insurance and can afford it. By the way, that brings down the cost of all the rest of our premiums because they get health care at the emergency room, and guess who pays. All the rest of us do, to the tune of a national average of about $1,000 per policy. This legislation will reduce the deficit, $130 billion over the next 10 years and over $650 billion in the second 10-year period. There is room for improvement. That is why we need to debate it. That is why we need to amend it. I will be offering an amendment that will produce savings to the taxpayers of another $100 billion by lowering the cost of drugs to Medicare recipients. Let the debate begin. I look forward to it.

Mr. NELSON of Florida. Mr. President, I rise to support the majority leader and his motion for cloture to cut off debate to allow us to vote on the motion to proceed which will allow us, then, to get the bill to the floor so that we can debate and start amending this bill. I wish to use the next several minutes to lay out a comprehensive reason of why this Senator supports moving to take up this legislation. I look forward to the amending process, and there will be vigorous attempts to amend it. I had offered a number of amendments in the Finance Committee. Most of those amendments were, in fact, adopted, but there was one in particular that was not adopted on a vote of 13 to 3. It would save the American taxpayers $109 billion by having the price of drugs that are sold to Medicare recipients under the Medicare Part D who also are eligible for Medicaid but get their drugs under Medicare, it would cause those drugs to be sold at the same discounts that they get the drugs under Medicaid. There have been discounts for a couple decades because of the bulk purchases of millions and millions. It is close to 50 million people who get drugs under Medicaid. There are about 43 million people who get their drugs under Medicare. Let me correct that. There are 43 million people on Medicare. There is some number less than that who are now getting their drugs under Medicare Part D. But, in fact, they don't get the same discounts that those very same people in Medicaid would get, even though they are eligible for those discounts. Those people are called dual eligibles because they are eligible because they are poor to get it under Medicaid, but they are also over 65. Therefore, dual eligibles should be able to get cheaper drugs. No, we can't do that. Because in the Medicare prescription drug benefit passed 6 years ago, those kinds of discounts were not allowed. That is a huge additional cost to the taxpayers. The overall amount of Medicare drugs being sold, if you got those discounts, would be something in excess of saving the American taxpayer $200 to $250 billion. For those who are dual eligible--they qualify for Medicaid but get their drugs under Medicare--the savings would be $109 billion. This Senator is going to offer that amendment. It is a high threshold of 60 votes that we have to get but, indeed, we will see and on down the line. Why am I insisting on continuing to offer this? Well, it is interesting that just recently an AARP study has come out, along with another study called IMS. They have noted that the cost of drugs, brand name drugs, their wholesale prices have increased, in the year 2008, 9.3 percent. Contrast that to the rate of inflation, which was about zero percent. So you see that the cost of drugs is continuing to go up. It is time to give our people some relief. We could do a lot with that extra $109 billion. First, we could lower the deficit by $109 billion. So whereas this bill brought forth by the majority leader saves the Treasury money over the 10-year period and reduces the deficit by $130 billion, we could add another $100 billion to that. We could be lowering the deficit $230 billion. But we could take part of that money that we would save the taxpayers and use that to fill the doughnut hole. That is the strange creature in statute that gives senior citizens under Medicare some reasonable compensation for their drugs, up to a certain level. That level is, generally, between about $2,500 and $4,500 of total drug purchases within a year. But once they get into that zone, that doughnut hole, in fact, they get no assistance from Medicare. That is called the doughnut hole. We could help senior citizens fill that doughnut hole so they are not bearing the full cost of those drugs when they get hit with huge drug expenses in a particular year. We will see what the will of the Senate is as we come out here and start to vote. The reason it is important, tomorrow night at 8, for us to get 60 votes to shut off debate is so we can go to the motion to proceed to get this bill to the floor. The reason is we need a debate. We can't afford not to have a debate. In what is known as the world's most deliberative body, that is what we do--debate and amend and try to perfect. Is anyone denying that health care, the cost of health care, the availability of health care, the availability of health insurance, the availability of health insurance at a reasonable price, is anybody disagreeing that is not a problem? Our people are hurting. One of the main purposes of bringing this legislation out here and trying to find a reasonable solution is to make health insurance and health care available and affordable. For example, what about if you have a preexisting condition. You can't get health insurance. We are going to change that in this legislation. What about if you are sick and your insurance company suddenly comes and says: We are going to take away your insurance, we are going to cancel your health insurance. Is that a good outcome? There is nobody in America who thinks that is a good outcome. That is what we are trying to change. By the way, that is what the bill proposed by the majority leader will, in fact, do. What about all those 46 million people who don't have health insurance? First of all, a lot of those folks do get health care, but where do they get it? They get it at the most expensive place at the most expensive time. They go to the emergency room, after what could have been very possibly prevented becomes an emergency. So it is at the most expensive place at the most expensive time. By the way, guess who pays. Do you think all those costs suddenly evaporate in the ether? No. They are costs in a hospital that are ultimately borne by all the people who support the health insurance system; that is, those who have health insurance policies and pay premiums. It is no small amount that we pay. As a matter of fact, nationwide, the additional cost to a family health insurance policy to take care of uninsured people is between $900 and $1,000 per year extra. It is a hidden tax on all the rest of the people who are paying their health insurance premiums. In my State of Florida, it is even higher. It is estimated to be $1,400 per family policy per year, a hidden tax. That is a hidden tax that will disappear, if we can bring in those 46 million people nationally who are uninsured, 4 million of whom are in Florida, if we can bring them into the system. Will we bring them into the system? The bill the majority leader has put on the table will cover 98 percent of all Americans with health insurance. That is the entire spectrum of Americans who receive health care. Is that worthwhile doing? I certainly think it is. I said at the outset this bill also tries to approach this in a responsible financial way. The actual cost of the bill is about $848 billion over 10 years. But that $848 billion is more than paid for because, at the end of that 10 years, there is an additional $130 billion that is left over. That is surplus that will go directly to lower the deficit. The projection by the Congressional Budget Office for the second 10-year period is at least a $650 billion reduction of the budget deficit in that 10-year period and possibly as high as $1 trillion in lowering the deficit. What does that tell us? What it tells us is that one of the reasons we need a bill coming out on the floor is that not only do our individual Americans have difficulty paying for the cost of health care, the U.S. Government is having difficulty paying for the cost explosion of Medicare. Unless we start getting those costs under control, then, in fact, we are going to be in an unsustainable proposition with Medicare. A system of revising health delivery capabilities so people are not being canceled, no preexisting conditions, people can get health insurance at affordable rates but at the same time starts lowering the overall cost to not only individuals but to the U.S. Government, it seems to me that is desirable. So you will hear and we have just heard comments about how Medicare is going to be cut. Well, there are clearly inefficiencies in Medicare that need to be wrung out. Let me give you an example. Right now, we have what is known as Medicare fee for service. It basically pays the doctor's bill that is submitted for the person who is eligible for Medicare. But what happens is, the Medicare patient goes to this specialist, that specialist, that specialist, and all of them are not talking to each other. This one orders this particular set of tests, and that one, because he does not know what the other one is doing, is ordering the same test, but Medicare is getting all of the same bills. This bill, in reforming health care delivery, is going to try to get at that. It is going to set up accountable care organizations. It is going to set up electronic records so there is no more of this shifting around and, oh, I didn't get the report. It is going to be there available immediately. These are obvious technology increases we have to do. That is Medicare fee for service. How about a program called Medicare Advantage? Let me tell you what Medicare Advantage is. Medicare Advantage is a fancy word for a Medicare HMO. Do you know what an HMO is? An HMO is an insurance company. It was originally designed in the late 1990s that you could deliver health care cheaper to senior citizens in Medicare through an HMO. So when it was first set up, Medicare HMOs were given 95 percent of fee for service because they were going to save costs. They were going to save costs to the individual, they were going to save costs to the government--95 percent. But, lo and behold, in 2003, in the Medicare prescription drug benefit, it not only set up what I described a while ago as this unusual doughnut hole and drugs that cannot be discounted to the Federal Government when it is buying drugs in bulk for millions of Medicare recipients, it also set up that we are going to give a cushy arrangement to insurance companies where insurance companies that want to sign up Medicare recipients are going to get 14 percent more per patient--114 percent instead of 100 percent of Medicare fee for service. Is it any wonder costs are exploding in Medicare if suddenly a program gets 14 percent more per patient than what the standard baseline ought to be, which is Medicare fee for service? It does not take a rocket scientist to figure that out. Because insurance companies--Medicare HMOs; the fancy name is ``Medicare Advantage''--because they get more, 14 percent more, then they can offer additional things to the senior citizens, and this has proved to be quite popular. Basically, 30 percent of all Medicare recipients in my State of Florida have signed up for Medicare Advantage. Indeed, the biggest thing they have that is desirable--you hear about eyeglasses and hearing assistance and so forth, but the biggest thing that is the most popular is that because the insurance company is getting paid so much more per person, it can then use part of that money to pay the copays on Medicare, such as Medicare hospital insurance, Part A and part B, as well as Part D, the drugs. So it is very popular. So what I said in the Finance Committee is--obviously, we ought to reform the system. And I can tell you, this Senator did not vote for it 6 years ago, which set up this system, which was a cushy system for insurance companies as well as the drug companies. But the fact is, we have not. So this Senator said, in the Finance Committee: All right, what I want to do is I want to grandfather the people who have it in Florida so that, on a going-forward basis, when this takes effect--in this bill, it takes effect in 2013--when it takes effect, it is only those new people signing up who will operate under the new system that will make it more streamlined but that those who have the existing benefits from Medicare Advantage will not be cut. I offered that amendment along with other Senators in the Senate Finance Committee, and that amendment was adopted. So the statements that have been made on this floor about Florida Medicare Advantage recipients being cut in Florida is not accurate on this bill. I fought for that. Everybody knew I fought for that. And of the 949,000 Medicare Advantage recipients in Florida, at least 800,000 are operative under the formula we put in and the remaining 149,000 virtually would not be affected anyway. I cannot speak for the other States, but I can sure speak for Florida. That is in this bill. Those other Senators who offered the amendment with me in the Finance Committee had things that tended to their States, as well, that were part of that amendment. But that is what the situation is with regard to this legislation. Let me say that if we can get this legislation out of the Senate and get it to a conference committee with the House, the House has a whole different approach. The House works on streamlining Medicare Advantage from the basis of not something known as competitive bid, which is in the Senate bill, but what is known as fee for service, as the target benchmark. That does not have the Draconian cuts, in my opinion, to many of our Medicare Advantage recipients. But I want the record clear here that with regard to Florida, Florida Medicare Advantage people have been grandfathered in of those who are in existence and those who still will be in existence having signed up for Medicare Advantage until the date at which the new system would start. I see we have changed Presiding Officers, and it is such a pleasure to have the esteemed Senator from Minnesota in the chair. Madam President, there is room for improvement. We spent 2 full weeks in the Senate Finance Committee on amending this legislation. We had spent 3 months prior to that discussing it. You can imagine, in a nation as diverse and complicated as ours and a health care industry where everybody and his brother and sister have their fingers in the pie, how complicated this is. But that is the reason for the amendatory process: to improve, to perfect. I want to wind up my remarks by giving a picture of the totality. We have had so much of the debate, ever since summer, dominate on the concept of a public plan. Many organizations have now come out and said that a public plan, at max, is going to affect 4 million or 6 million people. If it affects 6 million people who sign up for a public plan-- if there is one in existence. And, of course, the majority leader has in here not one that is mandatory. He has it as an option where a State can withdraw from having a public plan. But if the max of 6 million people signed up on a public plan, that is 2 percent of the entire country. Yet you would think that was the only thing when you listen to the arguments--and sometimes we watched fights in these townhall meetings back in the summer--you would think that was the only thing this whole health care reform was about. In the max, it is going to affect 2 percent. Why is that? Why is it that it only affects 2 percent? Well, look at the whole population to whom we want to give health care delivery. Take my State of Florida. Approximately--and I am rounding these numbers--approximately 50 percent of our people in Florida get their health insurance from their employer and they are in a group policy. Another 16 percent in my State get their health care from Medicare because they are eligible at their age. Another 10 percent in my State get their health care from Medicaid because they are either qualified under the income level or they are disabled. Now add that up. That is 76 percent right there of all the people of Florida. That includes children. OK. What about the remaining 24 percent? About 4 or 5 percent of our people also have health insurance but they pay through the nose because they are buying it as individuals as opposed to a group policy. If you are buying it individually, where all the health risk is on one life, the cost of those premiums is very high. The remaining 19 percent are the uninsured. That is as to the population of my State of Florida. That will vary with different States. Obviously, in Florida we have more people aged 65 and older and therefore eligible for Medicare than most States. But you can see now that what we are going to do is, over here for this remaining 24 percent, we are going to set up a health insurance exchange. In the case of Florida, it is going to have potentially 4 million people in it. It is going to be the uninsured who are now going to have access to health insurance with no preconditions, and they cannot cancel their policies, and it is affordable. It is also going to be available to those people who, in fact, have policies they cannot afford, usually the individual policies. There will be some small business employers--for example, those with 50 employees or fewer--who will not be offering health insurance, and their employees will, for the first time, be able to go to the health insurance exchange and be able to get health insurance. All right. The competition in that health insurance exchange is going to have a public plan, if a State approves. That is why it comes down to such a small percentage. That is why an issue has dominated the debate but is not the main issue. The main issue of this legislation is to provide health insurance and health care to our people that is available and affordable. I will close with this: We have all heard these stories because people have been coming to us in our townhall meetings, on the phone, in the airport, back during the parades, at the meetings, and they have been telling us these very tragic stories: the woman who is in the middle of chemotherapy and suddenly gets a cancellation notice from her health insurance company; the person who desperately needs health insurance and can't get it and who has had it for some period of time; the person who is hanging on for dear life to that job because that job they have is not only their means of financial remuneration but is also their ticket to having health insurance. These are the tragic stories we want to change. We want to make people's lives better. We have to start somewhere. That point of starting is going to be at 8 o'clock tomorrow night, Saturday night, because the Senators are going to parade on this floor and indicate yea or nay on whether we are going to shut off the filibuster in order to get to the motion to proceed which will then allow us to get to the bill after Thanksgiving. It is absolutely essential for the sake of our people that we bring this legislation to the floor and that ultimately we get a product we can pass and get it on to a conference with the House and have an agreement that the President can then sign into law. Madam President, I yield the floor.

Mr. NELSON of Florida. Mr. President, I will vote for the motion to proceed. That gets us to the point at which we can have the bill before the Senate in order to debate and to amend the legislation. It is a debate we must have. It is a debate we cannot afford not to have.

Mr. NELSON of Florida

Mr. NELSON of Florida. Madam President, I hope Senator Byrd may be within the reach of my voice because I wish to add my voice to the many who have commended him for his public service, especially today as we mark a milestone in the history of this Nation because our Senate colleague, our President pro tempore, becomes the longest serving Federal lawmaker since the founding of this country. Many this week are depicting Robert Byrd's long list of achievements in numbers, and it is large numbers, and there are certainly many of those achievements. The Senator from West Virginia, for instance, actually began serving in the Senate the same year that Alaska became a State, 1959. He has been elected to no fewer than nine Senate terms. Before the Senate, he served in the House for 6 years, and now in the Senate for 50 years, 10 months, and 18 days. He has cast well over 18,500 votes. Senator Byrd has presided over the longest session of the Senate-- more than 21 hours--and he has presided over the shortest. We have had no fewer than 11 Presidents since he first took office. But the numbers don't tell all of the story because Robert Byrd has been one of the greatest representatives of and advocates for the folks in his beloved State of West Virginia. He is that larger-than-life, that iconic figure in our Nation's history too. He is the Senate's premier Member-observer. He is the Senate's institutional history. I flash back to that first day--and you never forget the first event of an occurrence in your life. It was my maiden speech, my first speech on the floor of the Senate 9\1/2\ years ago. I was at one of those junior desks right over there. I gave my maiden speech. It was actually on the budget. We happened to have a surplus then. I was laying out how we ought to preserve that surplus; as a matter of fact, even use it to pay down the national debt. I happened to mention in the course of my remarks that it was my maiden speech. All of a sudden those doors swung open and in strode Senator Byrd, that white shock of hair flowing as he took his place over there on the center aisle. As I finished my remarks, he said: Will the Senator from Florida yield? And I said: Of course, I yield to the senior Senator from West Virginia. Senator Byrd proceeded to give extemporaneously a history of the maiden speeches in the Senate. Of course, I was spellbound, I was awestruck, as I listened to this walking American political history book recite from memory, on that particular occasion, something that had been important to this Senator on the occasion of my very first speech in this extraordinary august body. Senator Byrd continues to be the Senate's conscience. In the spirit of Thomas Jefferson, Robert Byrd has always put public service ahead of personal fortune. On many of our desks--and it is certainly in my personal office in the Senate--are Senator Byrd's addresses on the history of the Senate. There were more than 100 of them delivered in the past 10-year period. They have been called the most ambitious study of the Senate that had ever been undertaken. Every day they serve to remind me of the living history of this institution and its vital role in our democracy. Senator Byrd has been a dear personal friend to so many of us. He has been such a mentor. Madam President, since the Vice President of the United States has just entered the Chamber, I wanted to recall for him that 9 years ago, in our freshman class of Senators, Senator Byrd took us on as a special project to teach us the protocol of how to preside. I can tell you what class a Presiding Officer comes from now, if it was a class that was under the tutelage of Senator Byrd, because there was a right way and a wrong way to preside in the Senate. The Vice President is acknowledging that is true. By the way, I have the privilege of standing at the desk the Vice President used to occupy. I particularly chose this desk because not only has he been such a great mentor to me personally but a very dear friend. With Senator Byrd, all of us grieved with him 3 years ago when his beloved wife Erma passed away. I know he yearns for her and wishes she could be by his side on this historic day. Now there is another number that is going to be important in Robert Byrd's life. In just 2 days, he celebrates his 92nd birthday. We all hope we can be here with him for many more years. Remember what President Reagan had to say about age and leadership. He said: I believe that Moses was 80 when God first commissioned him for public service. If the Lord is using that same commissioning for Senator Byrd, at 92, he has a long way to go. The Lord would certainly say to Senator Byrd: Well done, my good and faithful servant. Madam President, I yield the floor.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, today I honor the life and service of SGT Robert Altman, United States Army. Sergeant Altman is a member of the greatest generation that selflessly served our Nation during a time of perhaps the world's greatest turmoil. He risked his life and endured almost unbearable pain and suffering as a prisoner of the Japanese during World War II. He gave so much--so that all of us might be free. Sergeant Altman was a crew member on a B-17 stationed at Clark Field in the Philippines. It was just 3 days after the attack on Pearl Harbor that his bomber, commanded by another Floridian, CPT Colin P. Kelly, Jr., loaded three 600-pound bombs and took off with orders to attack airfields on what is now Taiwan. On the way, the crew spotted a large Japanese invasion force landing on the north coast of Luzon in the Philippines. Captain Kelly radioed Clark Field for permission to attack. But two calls brought only a response to stand by. Kelly and the crew made two practice runs at 20,000 feet, and then the bombardier released the bombs in a line from the carrier's stern to its bow. According to Sergeant Altman, two of the three bombs bracketed the ship; one was a direct hit. The enemy boat began to sink and was scuttled by its captain. On the way home to Clark Field, their lone B-17 was attacked and set aflame by Japanese Zeros. Kelly stayed with the plane long enough to allow everyone else to bail out, before he went down within miles of the airfield. Captain Kelly's body was found near the site. Sergeant Altman suffered serious injuries and soon after was offered a flight to safety. But he turned it down believing he could better serve his country by staying. He was subsequently captured and taken to Japan, where he was held as a POW for 40 months. During that time, he was forced into slave labor for the Japanese until his release from Omori Prison, Tokyo Bay on August 29, 1945. But it was the early report of his and his crew's heroism in that attack after Pearl Harbor that inspired a nation reeling in shock. Alone and far from friendly territory, Sergeant Altman and his fellow heroes served their country well. Today, Bob is an avid Florida Gator fan and I will have the honor of presenting him this statement before the game on November 21. Captain Kelly's younger sister, Emmy, and her children, Mary and Colin, will be there, too. I would hope Bob gets to see many more games. Today, I send best wishes from the U.S. Senate to SGT Robert Altman and his family and friends, including the family of CPT Colin P. Kelly, Jr.

Mr. NELSON of Florida

Mr. NELSON of Florida. Mr. President, I wish to be recognized as in morning business.

Mr. NELSON of Florida. Mr. President, it goes without saying that NASA, the National Aeronautics and Space Administration, is at a crossroads. It is an agency that has been starved of funds, so it finds itself in the position that its human-rated capable vehicle, the space shuttle, will be ceasing to fly after six more flights that will continue to build the space station and equip it. This last flight will probably not be until the first quarter of 2011. But the crossroads NASA is facing is because it has been starved of funds over the course of the last half a dozen years, it will not have a new human-rated vehicle to take our crews to the International Space Station. As a matter of fact, there is a great deal of consternation and conflict within NASA itself as to what that vehicle should be. So the President, recognizing this earlier when he appointed the new NASA Administrator, GEN Charlie Bolden, set up a blue ribbon panel headed by Norman Augustine. They have now reported, and the strong inference of their extensive and detailed report is that the vehicle that was planned to fly but was obviously going to be delayed because it hadn't been developed quickly enough, the Ares I--by the way, the same vehicle that had a very successful test flight a week ago--the strong inference of the Augustine Commission Report is that the Ares I would not even be ready to fly astronauts until the year 2017. Its sole purpose would be, according to the Augustine Commission Report, to get astronauts to and from the space station, and that would be, in the Augustine report's inference, too late. So they are recommending, or at least the strong inference of the recommendation in the Augustine report, is that commercial vehicles be developed to take cargo and crew to the International Space Station. The Augustine Commission Report is suggesting the space station certainly should be kept alive until the year 2020, but to now start to reap some of the science from the experiments that just now the space station is getting equipped to be able to do, in the nodule that is now designated as a national laboratory on the International Space Station. If what I have said sounds confusing, indeed it is. That is why NASA is at a crossroads. NASA is even more at a crossroads because NASA can't do anything unless it gets some serious new additional money, and that is the strong recommendation of the Augustine Commission Report. What they are saying is that NASA should have $1 billion extra over the President's request in this fiscal year, the fiscal year that started October 1 known as fiscal year 2010, and that the next fiscal year it should have an additional $2 billion over the President's baseline recommendation in the budget, and that thereafter, for the decade, it should have an additional $3 billion per year to fill out the decade so that NASA can do what it does best. What does it do best? It explores the unknown. It explores the heavens. What should that architecture be? I don't think our Senate committee can decide that. I don't think the White House can decide that, but the White House can give direction and our committee can give direction to NASA to go figure it out: Figure out what that architecture is to do what NASA does best, which is explore the heavens. That direction is certainly recommended in the Augustine Commission Report as: Get out of low Earth orbit. Expand out into the cosmos, with humans, to explore. So what I am hoping the President of the United States, Barack Obama, is going to do, now that he has received the Augustine Commission Report--it is my hope, it is my plea to the President that he will take their recommendations seriously and that he will do three things. First, even in the midst of an economic recession, when the budgets are very constrained and tight, he will say that a part of America we are not going to give up is our role as explorers and that he will commit to recommend in his budgets the additional money as recommended by the Augustine Commission, and in this first year, this fiscal year we are in now, fiscal year 2010, that is a lot easier because you can get that additional $1 billion out of the unused money in the stimulus bill. But it gets tougher as we get on down the line. That is the first thing. The second thing the President should say to his administrator of NASA, General Bolden, is convene the guys and determine the architecture of how we should go about and what is the mission we are going to explore. I can tell my colleagues that this Senator thinks the goal should be to go to Mars. It may not be to the surface of Mars; it may be first to Phobos, one of the moons of Mars; we would have to spend so much less energy in getting down to the surface of that moon because of the gravitational pull instead of going all the way to the surface of Mars. The science that we could gain from that would be extraordinary. Therefore, the President's direction, I would hope, to NASA would be: Figure out the architecture. Does that mean we are going to take the Ares I and make it into an Ares V? Is that going to be the heavy lift vehicle to get the hardware up to expand out into the cosmos, be it to Phobos, be it to an astroid, be it to the Moon? My hope is that the President would give that direction: Figure out that architecture and what are the steps along to the goal of getting to Mars. That would be the second thing. The third thing I hope the President would do is give direction to NASA that since NASA is at this crossroads and since there is going to be disruption in the workforce because there is not another human-rated rocket ready after the space shuttle is shut down, then you have to help the workforce. You have to move work around among the NASA centers. You have to bring in new kinds of research and development, of which NASA is a good example of an R&D agency. It is through the direction of those three things that I think we can get NASA out of this fix it finds itself in at this crossroads point. Give the direction, No. 1, for the additional funding that NASA needs; No. 2, direct NASA to produce that architecture for exploring the heavens; and No. 3, take care of the workforce in the meantime. Mr. President, I yield the floor and I suggest the absence of a quorum.

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

Mr. NELSON of Florida. Mr. President, the Food and Drug Administration is proposing a rule that will basically eliminate raw oysters from the Gulf of Mexico. There have been 15 people in the past year who have died from a bacterial infection that comes out of raw oysters. But what has been discovered is that the people had a preexisting condition prior to eating the oysters that made their immune system wear down so they were much more susceptible. In a sweeping administrative executive branch decision trying to correct a problem, they are suddenly proposing that they are going to stop the rest of America eating raw oysters from the Gulf of Mexico. This is like saying: If you have a food allergy to peanuts, we are going to ban you eating peanuts unless you cook them. There is a thriving industry along the coast of America, particularly the gulf coast, that has a delicacy known as raw oysters that people enjoy. Apalachicola oysters, the creme de la creme, are shipped all over the world. And in some of the fanciest restaurants you get Apalachicola oysters on the half shell. The Food and Drug Administration is about to basically ban raw oysters from the Gulf of Mexico. Some of us in the Senate are going to try not to let it happen. Senator Landrieu and I, who both have some interest in this because it affects our States, are filing a bill today that would utilize the appropriations means of not letting an appropriation be enacted or used for the purpose of the FDA implementing such a rule that would basically ban raw oysters from the Gulf of Mexico. This is trying to kill a gnat with a sledgehammer. If people were, because of a preexisting condition, already subject to coming down with an illness, there is simply no sense. This is government run amok. This is government out of control. This is government trying to kill a gnat with a sledgehammer. We are not going to let it happen. I inform the Senate today that we are filing this legislation. I yield the floor and suggest the absence of a quorum.