the benefits package it's up to the discretion of washington bureaucrats might be helpful in this debate to be reminded that when the original medicaid nothing in the bills stated abortions would be covered and because of that comprehensive care including reproductive that's going to be absolutely vital what about some of the groups administration is influenced by the national abortion federation on their  in terms of abortion services and that is the way we think we ought to leave this discussion is the best way to be able to address the sometimes controversial issue what we don't want to do is to make a statement that would suggest denial of critical services for women that is provided under most private insurance in this country and so therefore we oppose this amendment  we see it differently and i want to be as respectful as possible the question here in the debate abortion the question is should we have an history in the was shows us that when abortion is not excluded it is included this is why we have in programs like s chip in the federal employee health benefit plan this is why we have the infamous hyde amendment it's very important to exclude such things and when we federation of saying health care reform supporting health care reform as a way to increase access to comprehensive reproductive health care including abortion care for all women and so we realize the intention is to cover we realize legal history shows us that if you  don't covered the point with the individual mandate will we tax individuals two point five percent of income if they do not buy a plan that does not include abortion services will we tax every employer eight percent of payroll of every worker if they do not offer health insurance that includes abortion if you don't exclude it explicitly then the answer becomes yes and so the question isn't whether you're pro life pro choice the question is do you think we should force taxpayers to pay for something that many believe is morally wrong and i think the answer and i think a lot of pro choice legislators on both sides of the aisle we have pro choice republicans democrats pro choice democrats pro choice republicans we mostly vote not to subsidize these things with taxpayer dollars because many of our constituents believe this is morally offensive and so let's simply apply those exclusions like we have in many other instances of law to this new law that's what this is about from texas what does it do what the amendment does do what the bill doesn't do is protect hospitals other providers who aren't being allowed a choice and at the end of the reclaiming my time that assumes the government plans are treating the uninsured and they're going to they're going to be treating people who have insurance today they're going to going into the government we had that debate earlier people who are being insured by the way at higher rates today we already heard about that between sixteen thousand dollars because just because of this issue that we're debating today i know that some of you on that side of the aisle that is to protect providers the health care twenty thank you mr chairman taxpayers have already bailed out banks financial institutions and automakers and under no circumstances should american taxpayers have to risk going to operate on actuarial including reserving like any other insurance and if the language in the bill does not satisfy the gentleman i believe there is a willingness on behalf of the majority to work with the gentleman to  chairman one other fact to put into this mix because i sense that maybe there there could be an accommodation based on the gentleman observation and that is the ambiguity about how much the fund actually has to repay it's not clear to me whether the fund is going to be required to pay back the two billion dollars to the taxpayer with interest or if that's an interest free loan over ten years one of the elements that i think should be on the table if we're going to have a competitive situation and not and an inherent advantage to the government plan is to make sure that it's paid back with interest that's appropriate and also within the budget within the budget window so that it's not perceived as members and these eighteen million americans will ultimately lose their health care without new members balance out the insurance pool the cost of these plans will skyrocket to the point that no one could afford these plans any longer it's a government run public plan isn't prohibited from enrolling new members it's only fair that individual plans my amendment would repeal the ban on rolling in individual health care plans strengthening our health care system begins by protecting americans freedom to choose the health care best for their their needs and i reserve the balance of my time for closing health insurance in the private marketplace the way it exists today which is why we are making a variety of changes in the rules for insurance companies whether they're in the exchange or not but in the exchange for individuals what we've said is that they will no longer be able to discriminate based on health status preexisting condition gender occupation that is one of the things we hear certainly yes as all of us hear from constituents about buying insurance and and finding it's very difficult to have them insurance cover what they need or not be able to buy insurance as an individual because they have a preexisting condition that is a huge problem for millions of americans that we solve in this health care  we will grandfather those who have current individual plans in going into the change in two thousand and thirteen individuals regardless of their preexisting condition will be able to choose amongst a variety of private options and a public option there  no direction by us in this bill as to what they will choose we expect and i know the other side is very skeptical about this that the private insurance market will not be interested in selling insurance to the additional thirty or forty million americans who are now on insured we don't think that's true we think that they have an interest in this market and they have said themselves the insurance industry is themselves they are willing and interested in complying with these new regulations they have said themselves that of all americans are in they are willing and in fact anticipating quite excited about creating the the right products to sell to this group of individuals so this is a way for us to make sure that individuals have options and those options are a variety of private options and yes a public option but again understand that even where we provide subsidies for those who are lower income there is no direction to the public option they may take that's up to the anywhere within the exchange with private insurers or the public option of a discreate a new level playing field for individuals who have essentially been left out of the marketplace now so we think we've actually done something really good to those who have had difficulty in buying  if you have a pool that has people in it and they are insured and you disallow any new people from being enrolled in that pool what happens the pool becomes much much much more expensive the pool gets older and sicker the pool goes away that doesn't jive very well with if you like what you have you can keep it eighteen million people have individual market insurance they have it they probably like it there's a company and he was gone and called assurance health care it's one of the largest individual market insurance providers in america the largest provider of insurance eight hundred of these employees would which are really good paying jobs reside in the district i represent you think assurance going to survive in this kind of a market place you know because you know what this bill does it repeals their marketplace and so the question is we hear all these words from the other side and competition in private insurance it always comes with one precursor in the exchange what is the exchange the exchange is a federal system a federally regulated heavily federally regulated system so that if you want to have insurance it's got to be insurance that the commissioner approves of well why don't we let people buy insurance maybe the commissioner doesn't approval why not let people buy insurance that can be tailor made to their needs why don't we let people buy insurance that they want to buy why don't we let people buy insurance outside of the exchange with ultimate freedom with ultimate consumer choice like they can today this denies them of that choice this denies them of that freedom this requires them to buy things they may not want to buy in this will and disputable irrefutably make the insurance that these eighteen million people have right now go much much much higher in price and make it more expensive and will make it impossible for these companies to survive and continue to offer the services that these eighteen million americans now enjoy that's why we say we want to help you make good on your rhetoric we want to help you connect the substance of your policy with the rhetoric of your speech so that truly on the individual market we can help people actually keep what they like we can actually help people have choices we can actually have competition because it is so very clear that this bill repealed all of those things it does not offer choices they're all different shades of the same color with the actuarial standard benefits and it doesn't give people freedom and it will and we will help you make good on your promises and on your rhetoric you mr chairman you know really doesn't matter how excited the majority is about a proposal or even the language of the president the united states when he says you want to keep your cool if you like your coverage you get to keep it all you've got to do let's just look at it together is look at the plain language of this bill and i know the bills been rushed through but we had a little bit of a conversation about it earlier on today section one hundred two individual health insurance insurer offering such coverage does not enroll any individual in such coverage if they have the first effective date of the coverage is on or after the day of year one in other words you don't get to replenish the pool if you're an individual insurance carrier you don't get to go back out and get healthy sold back in so ultimately this clearly by definition this becomes a self fulfilling prophecy where the people who are as mr ryan mentioned eighteen million americans who are in this and presumably satisfied that pool is ultimately over a period of time if it is not replenished you cannot reconcile this language with the promise of president  obama they are inconsistent you cannot bring them together there is no way that the president's promise allowing americans to keep the coverage that they like reconcile with i'm sorry mr chairman did you recognize me to close thank you sir just to kind of a pull this all together and wrap it up people have talked about the language restricting people to enroll in these individual health care plans but there's also some additional language in this bill that constricts even these into the individual plans even further and that is they're not allowed to add any new benefits to their plan that means no new technology no new medication or drugs no new therapies can be added to their plan that can be added to this plan the only thing that can be changed in this individual health care plan is the cost and the only way that's going to go so the only thing that can change in this plan is increase your premium so where is the choice if i'm enrolled in this individual plan and i don't have the same advantages as some of the other plans better technology better medication that have come on in the next five or seven years then i'm going to be shifted over and forced  one amendment thank you mr chairman we've heard a lot earlier in the day from the cvo director about the significant long term cost of this bill with regard to health care and  how this will significantly effect the deficit in a negative way this amendment is about bringing down costs and health care it's about going at this a little different way rather than saying how much we can spend in taxes to provide health care this is about bringing down costs in this amendment would delay the effective date of the additional tax increases including the individual surtax which we heard goes down to income levels as low as nine thousand dollars for a single and eighteen thousand dollars for a couple of small business tax the international tax provisions and the economic substance doctrine until the general accounting office g a o certifies that the medicare fraud rate has been reduced to below one percent of total claims it's unfair to ask the american people and american employers for more of their money when so much is already wasted and medicare fraud continues to be so rampant according to the chief counsel to the health human services inspector general i'm quoting a lot of career criminals in organized criminals have decided that building a medicare fraud scam is far safer than dealing in crack or dealing in stolen cars and it's far more lucrative right now it's a good bet that you can take millions from us and chances are you're not going to get caught and according to the head of the justice department's health care fraud section and i'm quoting again once you or someone who wants to commit fraud have patients with medicare numbers and those patients are willing to cooperate with you you can commit any kind of fraud you want and quote weekly had an article that said the government accountability office has read it rated medicare at high risk of fraud and waste every year since one thousand nine hundred in part because of its sheer size and complexity best guess is put the total cost of medicare fraud it between twelve and thirteen billion dollars a year and the estimates imprecise because many medicare frauds are never discovered the article went on to say the government has never done a particularly good job detecting fraud in medicare much less preventing fraud in the first place most claims are never checked at all this amendment would not only require that all of the tax increases in the bill be suspended until the fraud rate is below one percent it would require to consult with the health and human services inspector general and the attorney general of the united states in making this determination and i would back the balance of my time this stock is ready but mr chairman i would have to classify this is the alice in wonderland amendment while we all agree that we should take steps to reduce medicare fraud never in the history of public or private insurance plans has fraud been reduced to one percent there is damage in large plans fraud sometimes mistakes four and a half million claims a day are processed by private insurance companies for the government a billion dollars a day is processed by private companies for the government you know the fraud losses were three point six percent as the national healthcare anti agree it basically says that for ever we will not raise taxes to fund this bill to provide health coverage for forty or fifty million people without it the idea that we would ever get to one percent is just not within the context of operating such a large and complex operation   perhaps we can cut fraud in half then if one percent is too low but i think when it comes to misuse of taxpayer dollars we shouldn't be too complacent about trying to reduce that to the lowest incentivize an attempt to get at this we know the government has done a terrible job in this and frankly medicare really doesn't have any program to try to stop the fraud in the system it's significant we've heard from high ranking government officials and health and human services and the just departments fraud section how easy it is to commit fraud in medicare and i think that there are steps that we can take to comments as well others would not be able to receive a medicare number because of the language in the bill let me as a former commander of a base i'm glad i'm not the person to ten thousand men and women their government is passing legislation that's going to put their hospital in jeopardy nor do i want to tell the twenty people in twenty one states their jobs are now in jeopardy because a government doesn't like certain types of hospitals what about the five billion dollars in investments do we really not care about the fact this might have on the market i want to point out the provisions in this bill restrict future growth for two hundred twenty two existing hospitals located in thirty one states in this country mr chairman because this provision causes problems that are bigger than those nine that's a pretty big problem the bill outlines this bill includes one half trillion dollars of job killers that are an attack on small business jobs an attack on investment in america and just for a bonus attack on charitable giving which affects our local nonprofits in a major way this small business tax comes at exactly the wrong time hitting the people who create as president obama often says seventy percent of all the new jobs in america now you will hear people say well this only affects four percent of all small businesses but that figure is meaningless that's because four percent of small businesses actually have more than fifty percent of all the income for small businesses this tax doesn't hit the wealthy this tax hits our small businesses in professional create jobs half of all small business income will be taxed which is why this is so fundamentally opposed by our small business community in america and why it's also fundamentally opposed by our manufacturing industry in america the one that has been hit equally hard in this country and ever  member professes to be supportive of to rebuild the manufacturing base yet today we're going to penalize companies for creating jobs here in america through this tax a point i'd like to make is that while people may say they're pointing and shooting at donald trump who they're hitting is that woman's retail shop on main street they're hitting that consulting service that has built itself up from one worker to fifteen it's hitting the professionals who spent a little longer time in college to get an extra degree has worked their lives to build up a successful business successful living for their family those are the people that we are punishing with this tax in the end in the day what we'll be doing is killing jobs in america and as if this attack on small business investment wasn't bad enough for some odd reason and the last moment the bill includes another thirty eight billion dollars of job killers for companies that in source jobs to america let me repeat that we're going to penalize companies for investing and creating jobs here in america who installers it makes absolutely no sense this will drive income tax rates for some of the the group that carries the biggest burden of taxes in america over fifty percent and thirty nine of our state that means it will be the law of the land and thirty nine of our states that uncle sam and the state government gets more from every dollar you  uncle sam has a bigger share in state government takes more than you get out of every hour of that you work out of every decision you make out of every dollar you try to bring home your family the first and largest claim will be  now thank you mr chairman i'll be brief here but i just want to make sure that the gentleman from texas understands that mr bush is no longer president which i know makes you happy but we shouldn't continue to blame bush especially when you guys have been in control of congress for three years now you've had lots of time now to do health care and and to talk about money you guys supported package that bought another trillion dollars and now you're going to spend another trillion and a half dollars i know the gentleman doesn't like president bush we've established that a long long time but the american people are past that now they have a new president and i would hope that you guys would come up with better solutions than blaming president bush will just kill brady i hope mr chairman every small business person america heard this discussion lead to members of congress who sit on their duffs take money from the government roll have declared that small business people just have it easy that the small business person who ran who borrowed money from all their friends maybe charged on the credit card took out a second mortgage basically risked everything to start a small business follow the american dream that has sweated payroll every two weeks for twenty years to build up a business meant timewasting their family to card risk basically rist everything to become again part of the american dream that this democratic congress believes that you have it easy so you need to pay an extra tax beyond what anyone else does to fund this health care mess it seems to me as revealing an ideology as we've seen tonight small business people the engine of america the job creators you've got it easy and so we're going to tax you more when tax you for your hard work even though you already carry sixty percent of the tax burden in america back you pay more now under president bush than you did under president clinton because the tax relief that was provided to small and middle class america but you've got it too easy so we're going to tax you for this health care chairman this image pretty straightforward it strikes the section that deletes medicare solvency trigger medicare right now according to trustees is a thirty eight trillion dollar unfunded liability it's probably a good idea to keep a solvent to trigger to get congress to act and acknowledge this fact turning the trigger off is sort of the physical equivalent of hear no evil see no evil this also requires the g a o to report on the impact of this act on the federal government's financial condition and it requires a long term cost estimate of what i mean when i say that if you bring up chart one please already from looking at the score of this bill which is obviously admittedly incomplete to close the gap and actually have this bill paid for the ten year window another three hundred billion dollars of savings would have to be accrued but the appreciation that the increase in the costs and the offsets that's grow by ten percent point is this according to m elmendorf earlier in testimony in senate budget committee according to the numbers we see right here we know that the costs are growing faster than the offsets in the out years what does that mean that means we know that we are creating a new unfunded liability for the federal government we know that we are creating a new entitlement and that this new entitlement we're creating here is not paid for at this new entitlement we're represent future unfunded liabilities for future taxpayers reviewing the ones we've already got medicare medicaid social security cordon the general countability office at sixty two trillion dollars unfunded liability that's sixty two trillion dollars that we would have to set aside today invested treasury rates if we want to make good on the promises we are already making to the people in america today to the three generations my mother's generation my generation my children's generation let's put it in a different way by the time my three kids are my age my kids are four six and seven i'm in my late thirty's the time my kids are my age they will have to pay twice the level of taxes we have paid today just to keep this government growing for them at that time putting it another way the last forty years on average we've had to pay about eighteen point three cents on every dollar just to keep the government federal government bills paid eighteen point three cents on every dollar made in america to pay for the entire federal government well according to the current projections before this bill would pass my three children when they were my age would have saved forty cents out of every single dollar made in america just to keep the federal government going at that time and so what are we doing with this bill we're creating other entitlement with a nother unfunded liability and what we ought to know is how big is this liability going to be how much more debt and obligations are going to pile on to the next generation here's the problem mr chairman just told us a few weeks ago that is in a handful of years our entire national debt will be as big as our entire economy hundred percent of gross domestic product there's going to come a day in this country where people will no longer buy our bonds there's going to come a day where the countries china your pan who buy forty eight percent of our bonds right now will not continue doing this and the reason they won't continue to buy our bonds is because they don't believe we're getting our fiscal house in order they have no reason to believe we're actually getting our fiscal situation under control they have no reason to believe we're passing a bill right here which nobody has read which we don't know how much it costs but we do know creates a new unfunded liability on top of the ones we already have this is why the bond traders will get us with a vengeance this is why we will have higher interest rates this is why we know irrefutably quantitatively we are consigning the next generation t inferior standard of living we know for a fact that economic growth per person according to the congressional budget office is far inferior for the next generation that is for us and so the question before us is number one should we fulfill the legacy of this country which prior generations have always taught us is leave the next generation better off more prosperous well we're not passing that test in my opinion with this bill but number let's at least a measure of how bad it is let's at least pass this so we have a measurement like the trustees already do for medicare like the trustees already do for social security let's have the same test to measure chairman and i think we all agree that we have to figure out a way to keep the cost down we talk about bending the cost curve and finding ways to make it so that all americans can afford their health care whether it's through medicare for seniors or whether it's through private insurance we know that the costs have gone up too quickly probably at a rate of two to three times faster than the growth in people's salaries and so it's unsustainable no doubt but we can do this one of two ways we can do this by telling doctors that when they go in to do surgery they can use a scalpel or they can you to meet me that this approach that my colleague and friend from wisconsin proposes would use a meat axe nor should policymakers walk into policy making for forty eight million seniors in america using a meat axe to to save medicare money we have to make the cuts smart we have to extract the waste we have to get rid of the fraud and we have to eliminate the abuse but if you just make an across the board cut as this amendment proposes you're taking out some abuse at the same time you're taking out reimbursement for doctors who are giving valuable care you don't distinguish you don't discriminate you simply say we're going to cut everything across the board good and bad the baby goes out with the bathwater and i don't believe forty eight million seniors wanted to make reforms that way rather than do that this led to that we have before us talks about making some smart reforms it talks about extracting savings by taking care of what i think everyone panel would agree is the main cause of the fraud and the abuse and the high cost of health care within the medicare system and that's overutilization the repetitive use of services procedures by providers that go well beyond which to provide a good outcome of health care for seniors who visit their doctor or their hospital if we target our reforms we strike like overutilization and we do it in ways that are smart we can save quite a bit this legislation will save half a trillion dollars by targeting but if you use the meat act approach that baby will go out with about bathwater in this case that senior gentleman's remarks i think they were very well spoken and i think what's important now is in order to sort of thing into the teacher budget window the full implementation of this bill delayed until after the next presidential election sometimes twenty four but in order to make the numbers look better they don't look good because we heard from the cvo director that the significantly increased long term increases the deficit long term the tax increase and eleven and i think that's what the gentleman's referring to in terms of trying to look good on paper but when we look at the reality this will jeopardize certainly the delivery of health care in america  then that is an indictment on the judgment of president obama and the house and senate democratic majority because the way the trigger works is it is up to the president to send legislation to congress fixing the problem the financial problem and for their majorit congress to deal with that legislation so it is not a meat axe unless president obama makes it a meat axe the second point of this amendment is find out how big the problem is we know already from testimony earlier today we're creating a new on the funded liability for our children and our grandchildren so the question before us is shouldn't we measure how big that liability is isn't that a good thing to do apparently those who are choosing to vote against this amendment do not respect the judgment of the president and their own leadership or this committee's judgment and they just don't want to know they just don't want to know how big of a debt we're piling on the next generation they just don't want would say that this amendment a week or so after we heard our president commit upon his visit to the vatican and that he wanted to work together with all of us to the pope i think maybe not  amendment is very similar to the last bush and related amendment that was proposed by mr johnson what we're trying to do here today and this evening and for the next several weeks is to reform the entire health care system to ensure that almost fifty million people who are uninsured have access to coverage and help make people's current coverage more affordable and comprehensive the gentleman who i consider a very good friend is making a political point that i believe distracts us from the larger picture of this monumental reform i urge my colleagues to oppose that there are a number of things that my tax money goes to that the federal government funds that i may not embrace or be supportive of but as an american citizen i know when i pay my taxes they're going my tax money is going for the greater good this bill requires the plans in the exchange coverage essential benefits hospital visits doctor visits and prescriptions drugs there's nothing that would require plans to cover abortion services i believe this is merely a political to here are important discussion of health reform into a more purely political discussion and again i urge my colleagues to really has no impact on health care sending nurses or social workers or paraprofessionals into the hole to talk to new mothers or to pregnant women  has been shown by multiple studies to reduce the number of low birth weight babies to get greater immunization of children get fewer child visits to emergency rooms reduce maternal depression and increase the duration between pregnancy now all of those are health related issues and we often focus in care of acute care we're great at taking care of people when they're sick or very ill or way down the line but everyone talks about we ought to talk about wellness we ought to talk about prevention we ought to talk about the things the president has put this plan on the table and suggested that it's a good idea to go about doing this to prevent the problem one of the reasons i went in child psychiatry is because help a child you're dealing with a person for forty fifty sixty seventy years if you get it when they're thirty or fifty you're dealing with a whole lot of pain and anguish and you have a much more difficult time changing the same is true in physical health if you get these kids immunized so they don't get measles and they don't get polio and they don't get all the childhood diseases that you can prevent or you help a woman get sure she gets her prenatal care so that she doesn't produce a little tiny because if we had given the woman enough prenatal care and taken care of her during those months in which she's developing the child you would not wind up spending anywhere from a quarter of a million to a half a million  one of those low birth weight babies every one of them you prevent you can take care of an awful lot of family visits so this is a very cost effective method for improving the health care of children mr lerner talks about all these other programs go check out much money most of all the last thing that happens here or in the legislature and they don't get funded so the president has put it in here and said we should fund it directly and start our kids out in the best way possible to make it in life and for that reason i would urge that you reject this amendment it is not in the best interest of children i don't really know who it's in the best interest because like the fram commercial says you either pay me now pay me later if you don't take care of kids in the hundred ninety was sixty seven billion dollars fifty eight billion dollars more than the estimate in one thousand nine hundred eighty seven mr chairman after the entire medicare program was launched house ways and means committee estimated that medicare would be spending about twelve billion dollars in one thousand nine hundred eighty the actual cost was one hundred and eleven billion dollars ninety nine billion dollars more than the estimate mr chairman  seventy two when you were just a young congressman in this body medicare and stage renal disease or dialysis program was enacted it was estimated at that time it would cost one hundred million dollars in one nine hundred seventy young daughters very concerned about the financial future of america when you look at the numbers this legislation somewhere between one point two and one point five trillion generate that the secretary is required to reduce spending to ensure budget neutrality i think it fits exactly with what the blue dogs are talking about exactly what mr hoyer is talking about and i hope that you will consider my democrat pedigree mr chairman in adopting this amendment iraq cost fifty billion dollars as we're headed north of one trillion dollars in addition if you recall during the debate over the medicare prescription drug bill one of the officials who made the concerns about the i have one request mr neeld i will withdraw the amendment members of this committee particularly blue dogs will continue to work on maybe not this particular that we're considering is going to impose massive new taxes on employers any employer does not provide government approved health coverage to its employees will be forced to pay an eight percent payroll tax in addition to the payroll taxes that are being paid already this tax would help finance the health insurance subsidies of families with up four hundred percent of poverty eighty eight thousand dollars for a family of four but the democratic proposal doesn't stop there under their proposal an employer who offers a government approved health insurance would still have to pay the eight percent tax for every employee who elects to purchase coverage through the exchange even though it fulfills the spirit and letter of the law by already providing an approved health plan for example if an employee making sixty thousand dollars a year declined the coverage offered by his or her employer enrolled in coverage through the exchange the employer would be forced to pay a forty eight hundred dollars tax on that employee on top of the cost of offer health coverage to the rest of the employees in the firm which are already in compliance with the federal proposal that we're hearing today this penalties agreed to employers can't control whether or not employees accept coverage or not there may be some good reasons an employee would choose not to enroll in their employer sponsored insurance for example trust a doctor may not be in a network if the plan is offered  in the plan offered by their employer the democrat proposal penalizes employers who can't afford to offer health insurance penalize employers for employees decision to take another type of insurance and penalize employers that offer the wrong type of insurance penalize employers don't contribute enough to the insurance and penalize employers that make paperwork all of this in compliance with that as yet to be determined arbitrary government health plan this amendment would strike the provision that imposes a tax on an employer when an employer declines an offer of creditable health coverage and instead buys coverage through the exchange even if that employee has high income high enough to be disqualified from receiving any of the subsidies that those taxes and with that i reserve the balance of my time to of yes mr chairman thank you with all due respect to the distinguished gentleman from michigan i would say that if there is a code word being used here today choice in this bill which actually decreases choice i have the title in front of me and it speaks of nothing that you referred to  would you like me to read the language now with your read the whole thing so you understand what this is all about i believe that i have mr chairman and i don't know the clear statement as there are no code words the statement of the language says if an employee declines an offer but otherwise obtained coverage in an exchange participating health benefit plan that means if i decline coverage on the or by a ploy covered on the business owner and i already have a certified plan that is passed through the health is our or a commissar that would be appointed in the socialistic system the reality of it is got in a double bind on being double taxed now the bottom line here is it creates a penalty based on a false assumption in your argument the first false assumption is a subjective point that the employer brings up or the employee brings up to say what is adequate for the employee limited by the federal government to define what i have to give to my employer and then the employer to find that it out of wood and walk away from the plan that i'm forced to pay for you've got a catch twenty two the reality of this is at the end of the day if there's taxation for somebody that doesn't choose to accept the employee plan and wants to go elsewhere as chasing a doctor and then finally your words don't appear anywhere in the section it's unfair to penalty tax the tax would result in businesses having a lay off workers cut wages or not to hire new workers we all know that our economy is struggling and unemployment is near ten percent requiring small businesses to pay a penalty taxes they cannot offer health care coverage is no way to help them stay in business during these tough times let alone keep good workers or create new jobs penalty tax would equally harm workers during the downturn meaning many of whom would bear the new costs through law work or wages this amendment recognizes the challenges facing small businesses by protecting them from the penalty tax would cause such hardship the u s chamber of commerce the national federation of independent businesses and the national retail federation have all expressed their concerns about this employer tax on behalf of more than three million american businesses that they represent panel in the course of deliberations on the crisis that many employers health insurance is that people who have health insurance now are  farmers to enter the small group market on their own with no leverage with no ability to negotiate and how expensive that has become and that's what we're trying to address and i share my friends concern that we don't increase the burden on small businesses unnecessarily that might affect their business decisions that's why in this bill we completely exempt small businesses from any penalty or any requirement to provide coverage for those of the payroll of over a quarter million dollars completely exempt and even at that level  harmless based on the analysis that we have with a quarter million dollar exemption that's already in the bill it would cover ninety six percent of the small businesses in the country and those above it already offering health care insurance so they don't have to worry amendment and your comments are welcomed and accepted and in good spirit but the bottom line is that this really is about small businesses and i appreciate working with the other side and  in protecting small businesses but this bill really doesn't go far enough to protect small businesses which we all know in this room is the job creator is the engine of our economy across this country in my own state five hundred forty thousand small businesses employ ninety four percent of the population in washington so i don't think we can do enough to protect these small businesses and keep them operating keep them at a point where they're healthy enough to continue to hire and reducing employees wages and i think it will result in employers deciding not to hire new employees even according to the white house's own economic model the employer mandate in the bill will agency will limit or deny nationwide and as we've discussed here comparative effectiveness research should not be missed by medicare to deprive us of medically necessary care this commonsense amendment would require us to seek a public recommendation from an existing independent panel of doctors with relevant clinical expertise the medicare coverage advisory committee chairman a i'd be happy to respond to and again i certainly appreciate the spirit in which my friend from louisiana is offering this man an amendment but let's be clear i think the text before us really has nothing to do with the comparative effectiveness research as written the criteria necessary for impaneling the new med subcommittee would be vetted by nearly every other national coverage determination irrespective of whether c m s was considering a research or any other type of scientific research but what this amendment does do is it places an unnecessary and potentially detrimental restrictions on the current current national coverage determination process the current standard for c m s national coverage determination that the treatment be reasonable and necessary and that's been the standard that's been used for decades for the diagnosis and treatment of any illness this amendment introduces a new and potentially conflicting terms of the medicare statute subcommittees the power to effectively stop and delay national coverage determination by adding months to the determination process and thereby jeopardizing potential important coverage for patient care so i  i don't see the reasoning why we need to change the term necessary and reasonable medical coverage in the standard that's been throughout the decades and it has actually a redundant element was the projections from the treasury c d o and joint tax commission in one thousand nine hundred ninety that my colleagues on the other side of the republican decade undermined with in my opinion reckless spending and reckless tax policies now next week we're going have an opportunity on the floor of the house to vote for pay go legislation let me describe there for a moment that legislation as described as economic principles  ensure that all new spending and tax cuts pay for so as not to add to the deficit deficit with deficits that will never be paid by anyone in this room but by our grandchildren the children our grandchildren i hope that my colleagues price of this legislation today not really year from now but i'd like to know today i'd like to know the impact on gross domestic product today when we vote on the bill i'd like to know today the impact on the could super but gentleman yield today  unfortunately it doesn't impact this piece of legislation having said that mr chairman i would urge my colleagues to support the americans right to know amendment and my colleagues including the believe that the government run plan and i'm quoting now pay providers rates higher than medicare rates any public option that reimburses providers based on medicare will ultimately undermine the ability of patien care or similarly the blue dogs who say that quote providers must be fairly reimbursed at negotiated rates using medicare below market rates would seriously weaken the financial stability of our local hospitals and doctors others on the other side of the aisle have similarly articulated a real reluctance i've noticed to put a great deal of confidence in creating a new government run health insurance program that has medicare rates at its foundation because i think the new democrat coalition and the blue dogs have articulated and i'm paraphrasing now but it's really a house of cards ultimately what it will do is it will create massive cost shifting and i think the new democrat coalition in the blue dogs got it right and recognizing this is what this amendment does is very simple it says that the secretary shall not payment rates for practitioners under public health insurance options the payment rates for similar services and providers under part of medicare but instead they need to go out into the marketplace and come up with an average of payment rates for private health insurance plans very straightforward and it's my hope that we'll be able to secure some support on the other side of the aisle and help the new democrat coalition follow through on their promises help the blue dogs follow through on pushing it is because we have something here that must be fixed if the long term strength of our economy is going to continue if we don't fix the health care problem we're not going to come out in the long run in very good shape the reason industry is interested in this is because the cost of health care makes them on competitive and they want a way to begin to reduce costs and every time we have a problem in this country we've got to stop all or social programs all or social insurance programs makes absolutely no sense at all so i urge that reject this amendment implies that it's going to go to ten percent and i guess it probably will and when it happens why we'll have to increase unemployment insurance or maybe we should cut unemployment insurance when things are going when the unemployment rate is going up that's another social insurance program and if you start connecting everything to what the economy is doing you're going to have an absolute mess when you need the services the three most chilling words in the english language are you have cancer today america has the best cancer survival rates in the world but that's not the case fifty percent more likely to die in the first five years from cancer in england any are in the united states today in for individual cancers the difference is even more frightening for women with breast cancer the survival rate and i stated eighty four percent and it's a mere sixty nine percent for men with prostrate cancer prostate cancer survivor right in the united states is nearly ninety two percent in england it's fifty one almost twice as likely to die from cancer in a government run program in england many are today in the private plans united states this is in large part because of in britain each year more than a million people wait average of four months be treated two hundred thousand some white more than half a year a clinical oncology study of the british lung cancer treatment found that one out of every five potentially curable patients became incurable while waiting for health care in a government run program earlier today we heard about the situation england where there rationing organization we have one in this bill today felt that one of the first there to treat women with a positive breast cancer they national plan decided it was just too costly for their woman we can't allow that in this bill we can allow that in america my man requires a cancer survival rate for patients in the government run plan would be no worse than the average survival rate for a patient in a private plane and if those cancer survival rates are worse than the government run plan then stopped and it is fixed we can create a national health care plan that treats our cancer patients as second rate citizens because they choose a government run play and dismantle and make sure we don't allow that to happen and i will do i can vote for this amendment this amendment creates an unlevel playing field between the public option in the private office in the exchange should private plans with worse cancer survival rates than the public option also be terminated from the exchange it is hypocritical to impose different restrictions on the public option option than we do for the private plans second consumers are going to vote with their feet consumers will have the choice of the plan that they want in the exchange plans will compete and try to attract consumers based on all of this one of them is go no one is forced to choose any particular plan if consumers don't think that the care provided by the public plan is providing good quality and needed care they can enroll in a different plan congress doesn't need to make this choice for them if private plans my good friend from texas look if private plans are so  if private plans are so effective then why are we afraid of the competition of a public one i don't understand that fourthly the public plan has overwhelming support the bill gives consumers a real choice of options in the exchange looting a public option public opinion  polls overwhelming that american voters want that public option let the american people decide whether they want to public option by letting their vote let them vote with their feet as they decide whether to enroll in the public plan or a private plan without limiting their choice and i say to my friend from texas we know that many people might be anxious about a public plan so people therefore will have the opportunity not to select the public plan and i will conclude what i said before challenge the basic premise of what mr brady has said that is we have the best health care in the world mr stark and i did a study a number of years ago there is a registry of all the cases in the world of chronic my lodge kept in milwaukee wisconsin and when you look at the data the united states is not number one in thirteen states the first thing that happens to you is you go to the hospital and they put one hundred twenty thousand dollars here before we begin the process i had a colleague from the state  is the way we ration in this country we do have the best care available if you have the money or a piece of plastic to get it and that's the real problem here it's not a public plan or a private plan because france is public finland is public norway is public sweden is public a lot of countries run public programs and have much better treatment and that's the real issue here health care system in the world and not only that we've made dramatic progress in eight of the ten most common cancers some of them breast and prostate we're getting very close to nearly making all the men live and  survive as evidence of that the rest of world flocking from countries with these national health care systems to america for their cancer treatment i know coming from texas medical center  because earlier this committee said it was just too inconvenient for americans to know what their wait times to see a doctor would be in this government run plan and then this committee voted to make sure that they weren't part of the government run plan maybe things would be different when it comes to cancer if members of congress had been part of this government plan what i don't want is an unlevel playing field i think will be people making less than two hundred fifty thousand dollars and is it also not the case that the pay or play eight percent payroll tax will be paid on payroll for people making less than two hundred fifty thousand dollars you pointed out this morning and in two thousand and nine would be eighteen thousand seven hundred dollars joint return nine thousand three hundred fifty dollars on an individual return so one would have to say that there would be taxes on individuals adjusted gross income less than two hundred thousand dollars in that circumstance and you also asked about the eight percent payroll tax that would be morning when discussing a similar issue both the congressional budget office and the joint committee when when we estimate the facts when we do distribution analysis we see the economics quote middle class families will see their taxes cut and no family making less than two hundred fifty thousand dollars will increase close quote well violates that promise and we want to help the majority help the president make good on his promise pass this amendment and we will make sure that families making less than two hundred fifty thousand dollars don't see their taxes increase as this bill does just that easy that simple these tax increases amount to a hundred ninety two billion dollars over ten years they're obviously not the major pay for in this bill are penalties designed to force people into the mandate obviously we have a the problem with that but more to the point this bill violates the kind of change most people thought they were getting when they went to the polls in november i bet if you ran a poll most people believe that if they make less than two hundred fifty thousand dollars they're not going to get their taxes increased because the man who became president told them they wouldn't get their taxes increased we make this bill law they get their taxes increased so we pass amendments that won't happen it's that simple  how we were going to pay for it just another entitlement some of us voted against things of that nature this is structured differently first of all his proposal would call for a significant increase in the deficit he's not talking about adjusting the program he's just talking about eliminating revenue and driving up the deficit  opt out get coverage when you need it and all of a sudden you make it impossible to have the insurance reforms that are critical here dealing with preexisting conditions ninety nine point one seven one percent of american taxpayers from dealing with the payroll tax i think that is a little bizarre i think it's a little expensive it's not increasing the income tax taking away some of the principals some of the fees and the regulating mechanisms to make sure the system works now if you want to cut the coverage cut the coverage or if you want to reduce revenues in one place replace them someplace else but don't destroy the principle of in insurance don't drive up the cost of the deficit that's what you did when you were in charge we're trying to avoid that and i think we've done a reasonably good job i would urge rejection of amendment that takes us back to the days when you were in charge sure all those arguments are fine and good but they completely neglect the fact that the biggest promise of the last campaign is being violated with this piece of legislation i would simply say i don't want to do a rehash of the prior history but when we were in this committee when we were in charge the majority offered a prescription drug bill that cost a trillion dollars so unpaid for i'd say you could easily prado back the trillion dollars in spending in this bill to pay for this the point is this you're violating his pledge this bill breaks the president's promise to the people of this country it's just that simple  americans have and that's about equivalent to the number of individuals that are insured under the federal employee health benefit program and in fact more than the number of individuals  to get rid of the new provision that was added in the wee hours of this morning imposes an eight point two billion dollars tax on these individuals again living in neighborhoods where the median income is under fifty thousand dollars from wisconsin pointed out just before this president said we're not going to raise taxes on individuals making under two hundred fifty thousand dollars a year you savings account as a method to try to seek out secure health care coverage that continues forward what we do say is this we're tired of hearing other stories of people who thought they had good coverage and either were deceived by the people that sold them a health plan or felt they had no choice because of cost  or other circumstances to buy what they unfortunate later on there was a deficient coverage for their healthcare needs we could talk about the stories of bankruptcy where virtually half of all americans who have a personal bankruptcy today find it attributable to a health care cost that they ultimately can sustain a child gets sick they can't afford to pay the cost of the hospital stay low and behold they lose their home they lose your car they lose everything and they find themselves in bankruptcy what we're trying to avoid is a situation where americans are do it to getting what they think will be good affordable coverage and find later on that it leaves them in a very difficult circumstance and so what we're going to finally do is say to all americans let's make this transparent so when you make a choice on what your coverage will be you can get coverage that really will be there for you when you need it and so it should surprise nobody that this reform proposal calls for minimum standards it provides for basic preventative care services that almost offer it actually provides for the first time that our children will have access to dental optical care to make sure that you can't go above a certain amount of cost for catastrophic care and so what we're trying to do is package in a way that it will be not only affordable but it will be quality health care for all americans and when you take a look at your coverage it'll be an honest policy that you can make sense out of and know what it will provide you you get to make a choice you want the cadillac of coverage you can get that you want a more basic plan you can do that as well but what we will do is demand that anyone who wishes to insure an american for health care that they meet a minimum standard because we're tired of hearing the stories of americans w go bankrupt because they were deceived in the policy they purchased and so this policy says nothing more than if you want to be part of this exchange to offer these americans a chance to have health care coverage you have to meet minimum threshold h s a can be part of that so long as it meets those minimum threshold if it doesn't just like any other policy it won't qualify and so mr chairman i think we want to give the american people something that's transparent honest affordable and offer and quality and if it does that it's in i don't think we want to do anything less because we know the stories that americans have faced we want to make sure that this is the last time we hear those stories with regard to part of the provision that deals with the elimination of a tax and exclusion for over the counter medicines and i think we want to be clear on something we want to have equal treatment for americans who try t deduct their health care expenses from their taxes they must have at least that amount of expenses that equals seven and a half percent of their income if you don't have expenses beyond seven a half percent of your income you won't get any deductions now we treat some other americans a little bit differently if you have an h s a you can deduct certain expenses that most americans don't have a just get deduct on their taxes and at same time if you have a flexible spending account you can deduct certain types of health care expenses that most americans who don't have flex your accounts and don't have h s a cannot and what we're simply saying is this if an american can deduct or take a tax credit or tax break out of his or her health expenses it should be done equally so that  we know american better than any other and so this amendment unfortunately would force us to accept policies that might not provide americans what they think they're getting and i don't think we want to go down that route and so for that amendment and the manager's amendment kind of sprung on this provision that we got about midnight last night that would deny the ability of people with h s a flexible spending accounts and other health related accounts to buy over the counter medicines for their themselves or their families now being able to use those accounts for that this helps people provide a more available less costly way to take care of their health care  needs and why this would be taken away when we're trying to make health care more of a vailable and more affordable in this country is beyond me now we're talking about almost forty seven million people that are going to be affected by this provision that has not been t subject of any hearing or any discussion before this time and now it's part of a proposal i would say i think the gentleman's amendment on this point is not about someone being deceived in their health care plan but being able to use these accounts to purchase medicines over the counter and the alternative is going to be that they're going to have to either do those  tax with after tax dollars or go to a doctor and get a prescription and that's exactly what trying to avoid when they can treat their medical needs in a less costly way so i would just say that this is an thinking of her as we're doing this and then a doctor a seventy year old doctor who said to me the best thing you did in health care was passed which has engaged patients like i've never seen in my entire career are involved with h s a and they believe that the language in the bill would have a devastating impact on the offering of h s a i know that's not your intent i believe what you say today i believe you're very sincere what i ask you as you support the amendment but i don't think we're going to have much luck in that but i ask you in two years if this provision does become law and the impact it curves there was mr cantor believes what i  believe mr camp believes in and many on this side of the aisle believe will occur and that is we will see a dive in the number of h s a throughout america i hope that your sincerity today of what you've said that you will work with us thank you very much very briefly listen you know either either you are going to allow the promise of the president to be fulfilled or not more than eight million people have  with all due deference to the gentleman from california i don't think we are here to cast judgment against those who believe that is appropriate for them or their family in fact the increasing number of people purchasing a reflective of the fact that they can have some backstop that a catastrophic coverage is something that allows them some sense of health care security and economic security to be used for training of primary care residents as in the underlying bill and also include pediatric specialists service residents pediatric medical specialties pediatric surgical specialties or pediatric psychiatric throughout our country this mr chairman by increased spending by reducing the low income subsidy for individuals being mandated to purchase insurance the subsidy would be reduced from four hundred percent of poverty to percentage that fully offset the cost of creating additional g m a slots which we believe would be over three hundred just a no legislator would qualify for low income subsidies under the current language in the bill i would hope that those of you on the other side of the aisle most notably mr ward's who i work with on this issue would be interested in working with me we move through the process on this issue which i believe is not just important but to many of our states and with a commitment from either you or mr schwartz i would be happy to withdraw my amendment news but directed towards primary care because of the importance of a need for primary care physicians i do agree with you that i think we need to increase the number of slots for residency programs including specialty resins poems i know mr probably is  also concerned about those so i would i would say i would be interested in working with you as we move forward to make sure that we have an adequate number of both primary and specialty training slots residency programs in this nation and i think that is going to take a little more work  not get done tonight i look forward to working in a bipartisan way to get that  patients often in the emergency room because they know they will be treated regardless of their ability to pay however the emergency room is the most expensive place to receive care the median cost of an emergency room would end volunteerism as we know it in this country by allowing people to take tax adduction current volunteerism people volunteer such as those doctors providing services to better the community to help people not to seek a tax break and where would it stop should we then provide a tax deduction services or part of the us such as pro bono work of attorneys for those who volunteer soup kitchens for those who walk dogs for local animal shelters i don't know well thank you mr chairman you know i'm sympathetic to what the gentleman from nevada is trying to get at in this bill but i would have to associate myself with the remarks of the gentleman from new york in urging no vote on this amendment for the reason state d i think it is a policy that is not i think it be an ill advised approach to this particular problem and for the reasons that the gentleman from new york mentioned i think would be a  two remaining amendments i will drop one of them because it was a centrally addressed this this amendment is the genesis of this comes from a lot of people in our district who do don't have very high expectations of congress but a major bills like this they expect this to do two things one to read and study the bill before we vote on it and then give them time to be able to read and study the bill as what does it just expresses a sense of congress in this committee each member that virus prior to voting on this massive health care bill each member will certify in the congressional record that he or chairman there are two directors scorekeeping provisions in this bill the first appears in section one sixty four the reinsurance program for retirees the amount of ten billion in the second appears in section two thousand to the public health investment fund in the amount of eight point seven billion for a total of about ninety eight point seven billion dollars both sections contain the budgetary implication language which basically is a direct scoring provision that's what we called it in the budget committee which effectively says don't count it taking it off budget funds basically will not be counted in the budget act and they'll be taken off budget i don't think this is the intention of the majority to do bases payments to medicare advantage plans and medicare fee for service as you may know medicare advantage plans provide benefits to seniors that traditionally medicare does not including dental and vision coverage in a bi down a part b premium these plans have consistently grown in popularity and seniors have become accustomed to the additional benefits that they receive from these plans the bill before us will reduce medicare advantage payments thus eradicating these additional benefits even med pac has said that is unlikely that such a change will happen without disrupting senior benefits medicare advantage plans care predominantly for special needs beneficiaries minorities and low income seniors this committee should be aware of this before votes to cut benefits to this group i also have ascertained that the average in that seniors will have to pay more for their benefits if this is acted is about one hundred fifty dollars in my area in mr meeks area in south florida it actually would be closer to five hundred dollars i only have the figures for florida i don't have the figures for other states but i know that in many other states particularly in rural areas these are very very popular  and can keep the wasteful government spending that med pac has said will cost us one hundred sixty five billion dollars over ten years we're paying medicare advantage fourteen percent more than we would pay for traditional medicare and there is no guarantee that beneficiaries receive any extra benefit indeed the plans they offer them and that would sort of be like offering the chairman and myself health care plans in a gym with high speed chair climbers or stair climbers we might be offered but we might not use them there's very little evidence that these plans are providing that the higher medicare premiums or the over payments if you will to the private plans are paid for by all taxpayers and medicare enrollees medicare and rowley's or down have to pay fifty dollars a year or more in their premiums to support the current over payments in the medicare advantage medicare advantage over payments encourage inefficient plans in the thank you mr chairman as you know in this bill there are some provisions that would cause would cause very serious harm to a skilled nursing facility in order to stave off some of the cuts and prevent any disruption to senior care this amendment would do three things first it would spread the forecast adjustment over a three year period giving nursing homes time to adapt to this regulatory change second the market basket and the productivity adjustment would not be changed in the house bill this amendment would permit nursing homes to retain their market basket the final component of the amendment would amend the rehospitalization provision to give the secretary of h h s authority to utilize a trigger if the provision does not yield the estimated savings by the end of the ten year period the trigger would actually allow the secretary to reduce the market basket by one person from twenty fifteen to twenty nine mr chairman the reason why i put this amendment in was to highlight the fact that one of the things that i learned very very rapidly when i chaired the health committee in the florida senate and had to deal with nursing homes is that unless there's adequate reimbursement for nursing homes you can have all of the regulations in the world and they become snakepit they become places that you would not want your loved one to be i am very concerned about the cuts in this bill nursing home and mr chairman i would like to work with you and certainly with mr stark that we are not jeopardizing the health and safety of our seniors meant to refocus our attention on fraud we've had a conversation earlier when mr camp offered his amendment and i want to try to describe this in another way last week the miami herald had an article where they described a man named jose luis perenna who is i think figuratively laughing at us right now mr pereira's according to the authorities ripped off medicare for fifty six million dollars he had an enterprising partner they were to thirty three year old guys and they've completely hustled the system and mr perez is gone he's described by the f b i as an international traveler and he is now at large fifty six million dollars over several years has gone we've had a conversation the seasoning and throughout the day and i think all of us recognize that  there's waste fraud and abuse within the system and to be fair i think the majority makes an attempt in their bill to try and get at it and there's some decent stuff there increasing some enforcement mechanism there  enhancing penalties but the problem is that for people like mr perenna and his partner efforts i don't get those guys in other words the paradigm has to shift in other words we've got to get to the point of sale on medicare and not have a pay now and chase later approach and that's exactly what the medicare system does and even some of the other changes frankly that the it calls on the secretary of health and human services to establish a system to use technology for real time data review to stop waste fraud and abuse at the point of sale not think about this we have we have a credit card economy that moves over eleven trillion dollars a year there's seven hundred million credit cards in place around the world are in circulation around the world and yet that industry is able to have their fraud number at point zero four seven percent not compare and contrast that we were sort of laughed off the stage when mr camp offered an amendment that said we had to have a goal of three or three and a half percent and that was like oh you're completely unrealistic and yet with another industry that's actually bigger than medicare they're they're beating a limit daylights out of us in terms of you and why is that because they do point of sale think about it p s and fed ex can track twenty three million packages every day and customers can track it in real time we can do this but it's going to take a paradigm shift i was told earlier in sort of these shuttles this diplomacy sort of staff discussions that there was some objection to this bill based on anybody's going to bring that up because simply with one outlay of fifty million dollars we get mister and his partners i think this is an idea whose time has come i know it's late but