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PROTECTING ACCESS TO MEDICARE ACT OF 2014
(Senate - March 31, 2014)

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[Pages S1840-S1856]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




               PROTECTING ACCESS TO MEDICARE ACT OF 2014

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will proceed to consideration of H.R. 4302, which the clerk will 
report.
  The legislative clerk read as follows:

       A bill (H.R. 4302) to amend the Social Security Act to 
     extend Medicare payments to physicians and other provisions 
     of the Medicare and Medicaid programs, and for other 
     purposes.

  The ACTING PRESIDENT pro tempore. Under the previous order the time 
until 5 p.m. will be equally divided and controlled between the two 
leaders or their designees.
  Mr. REID. Mr. President, I suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. REID. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. REID. I would now suggest the absence of a quorum and have the 
time divided equally between both sides.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. CORNYN. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.


                              The Economy

  Mr. CORNYN. Mr. President, America's top priority is the same today 
as it was last year, the year before that, and the year before that: 
unemployment, jobs, and how to get this economy growing again.
  Of course, these are concerns which transcend any kind of partisan 
affiliation. They transcend geographic and demographic boundaries. They 
are shared, of course, by Republicans, Democrats, Independents--
everyone--people from all parts of our country.
  But the sad fact is it has been almost 5 years since America's 
official economic recovery began and still too many people who want to 
work can't find a job. There are still 3.8 million people who have been 
unemployed for more than 6 months, and the labor force participation 
rate remains stuck at 63 percent. Of course, those are the people who 
don't even show up on the unemployment statistics because they have 
given up looking for work. This is what we talk about when we are 
talking about the labor participation rate--the lowest number since 30 
years ago.
  Since the current President took office, the average amount of time 
the unemployed have been without a job has almost doubled, from less 
than 20 weeks to more than 37 weeks. This is a shocking statistic.
  So since President Obama has been in office, the average time people 
have been unemployed--have been out of work--went from less than 20 
weeks to now 37 weeks, and the number of people on food stamps has 
increased from 32.2 million to nearly 46.8 million people.
  As for median household income, it is now more than $2,400 lower than 
it was at the end of the recession in June of 2009. The President talks 
a lot about

[[Page S1841]]

income inequality, but the problem is, it has gotten worse since he has 
been in office, not better.

  We should be focused like a laser on things we might be able to do to 
set the stage to help the economy start growing again, because only 
when the economy grows do we see the unemployment numbers go down, do 
we see the labor participation rate go up, and we see regular American 
families have the opportunity to provide for themselves and to pursue 
their dreams. But right now that American dream is somewhat cloudy. 
Many people feel as though it is starting to pass them by, and that is 
the American tragedy. So you would think that at a time when there is a 
bipartisan consensus we need to get the economy moving again, we need 
to get people back to work so they can provide for their families, that 
there would be bipartisan agreement here in the Senate that anybody 
with a good idea ought to step up, offer it, debate it, and let's vote 
on it.
  Well, unfortunately, the majority leader has a different point of 
view. He is refusing to let anyone on this side of the aisle offer any 
suggestions in the form of amendments that actually might have a chance 
of improving the situation for people who are out of work or people 
looking for jobs. Not only is the majority leader blocking votes on 
bills that would make it easier for Americans to find work, he is also 
promoting and defending policies that would actually discourage work. 
For example, both the majority leader and President Obama are 
advocating a minimum wage increase of 40 percent, while the 
Congressional Budget Office has told us it could destroy up to 1 
million jobs.
  Now the majority leader and the President may not agree with that 
estimate, but I will remind them of what Federal Reserve Chairwoman 
Janet Yellin said; she is President Obama's own appointee as Chairman 
of the Federal Reserve Board. She said she wouldn't want to argue with 
the Congressional Budget Office's assessment about the number of people 
who would be put out of work if you raised the minimum wage by 40 
percent. For that matter, the evidence suggests that any increase in 
the minimum wage would destroy jobs and do very little, if anything, to 
reduce poverty rates. The best thing we could do is to get out of the 
way and let the economy grow again by making the environment more 
conducive to the people who invest, take risks, and start businesses or 
grow small businesses. That is the thing we could do that would help 
people the most.
  But in addition to the minimum wage increase, the majority leader and 
President Obama are pushing for yet another extension of long-term 
unemployment benefits, even though President Obama's own former chief 
White House economist has said that ``job search is inversely related 
to the generosity of unemployment benefits.'' So, in other words, 
people react in situs, and when the government continues to pay 
unemployment benefits for people who are out of work, human nature is 
such that people are disincentivized to go back to work and look for 
work on occasion.
  We all recognize the importance of this safety net program, and the 
truth is under the current law 26 weeks or 6 months are available for 
unemployment benefits. But under this administration we have seen 
unemployment benefits go from 6 months to 2 years. Two years after 
people have been out of work and those benefits lapsed, we have done 
nothing to improve job training programs that would help match the 
skills of out-of-work Americans to the jobs that are out there which 
pay good money--and I have seen many of them in my State, and I am sure 
the Presiding Officer has as well. We have seen a lot of good jobs go 
wanting for lack of a skilled workforce to be able to perform those 
jobs. So what we ought to be doing instead of extending unemployment 
benefits is we ought to be focusing on how we can train workers and 
provide them with the skills they need in order to qualify for those 
good, high-paying jobs.
  At a time when the American people are desperate for more jobs and 
more work, the majority leader is steadfastly determined to pass 
legislation which would disincentivize people from going back and 
looking for work and would in fact discourage work and discourage job 
creation. That is before we even get to ObamaCare, a law the 
Congressional Budget Office has estimated would effectively reduce the 
size of America's labor force by 2.5 million people over the next 
decade. Remarkably, I guess trying to spin it any way they could, the 
White House actually took the position that was actually a good thing 
because people would have more time off.
  Perhaps we shouldn't be surprised. After all, this is the same 
administration that unilaterally gutted the work requirements in the 
1996 welfare reform law, one of the most successful welfare reform laws 
ever passed. It is the same administration that refuses to approve the 
Keystone XL Pipeline, a project that would directly create thousands of 
new jobs right here in the United States, and it is the same 
administration that refuses to embrace progrowth tax reform.
  America's corporate tax rate is the highest in the world, and yet the 
President said he won't enter negotiations to reduce those rates, to 
eliminate double taxation so people will bring the money they earn 
overseas back here to hire more Americans and to build their businesses 
here. The President won't do that without an agreement on this side of 
the aisle to raise taxes, to raise revenue by $1 trillion. That is not 
a bargain we are interested in negotiating. This is the same 
administration that refuses to support energy, the energy renaissance 
we have seen, and continues to support regulations which actually 
threaten jobs and hurt families in return for meager or nonexistent 
benefits.
  As I have said before, this administration and its policies have 
become nothing less than a war on the American worker. I am not 
suggesting that is their intention, but I am suggesting that is the 
result.
  If there is one thing we ought to all be able to agree upon it is 
that work is about basic human dignity. It is about self-worth and 
self-reliance; it is about giving people the opportunity to reach their 
full potential and to support their families. When the policies of the 
Federal Government actually discourage people from working, it makes it 
harder for teenagers to learn basic social skills and professional 
skills. It makes it harder for college graduates to utilize their 
education and pay off their student loan debt. It makes it harder for 
people of all backgrounds to start families. It makes it harder for 
mothers and fathers to gain the self-respect that comes from providing 
for your own children.
  It is bad enough that the President and the majority leader have 
embraced an agenda that is fundamentally antiwork. What makes it even 
more outrageous is that this week the majority leader will deny the 
opportunity for anyone on this side of the aisle to offer any sort of 
constructive suggestions about how to deal with that problem. He is 
refusing to allow proposals that would actually encourage work and 
encourage job creation.
  Here are just a few examples of the amendments and proposals that 
would come from this side of the aisle if the majority leader--it is 
his sole prerogative--would allow those amendments to be debated and 
voted on by the Senate:
  For example, the senior Senator from Maine has a bill that would 
relieve the burden of ObamaCare on workers and businesses alike and 
restore the traditional 40-hour workweek. This has been one of the 
primary complaints of organized labor, some of the biggest supporters 
of ObamaCare. They said that in order to avoid the penalties that go 
along with ObamaCare, many employers are moving people from full-time 
work to part-time work. The amendment from the senior Senator from 
Maine, Senator Collins, would address that problem and fix it.
  The senior Senator from Utah, Senator Hatch, has a bill that would 
abolish the job-killing tax on medical innovation.
  The junior Senator from Missouri has a bill that would exempt 
military veterans from ObamaCare's employer mandate.
  The junior Senator from Kentucky has a bill that would make it easier 
for Congress to block regulations that do not pass a simple cost-
benefit test.
  The junior Senator from South Carolina has a bill that would 
modernize

[[Page S1842]]

workforce training and eliminate duplicative government programs--
something I was just talking about a moment ago.
  The senior Senator from North Dakota has a bill that would 
singlehandedly create thousands of jobs by approving the Keystone XL 
Pipeline.
  If and when these bills are offered as amendments to the pending 
legislation, they deserve a vote, but if the majority leader denies 
them a vote, he is effectively denying us a chance to expand our 
economy, create more jobs, and get people back to work. I used to think 
this was something Republicans and Democrats both agreed was a good 
thing. I thought we all agreed that job creation and work promotion 
should be the cornerstones of our economic agenda. With an agenda such 
as that, perhaps we could finally have a recovery of our economy worthy 
of its name.
  So I hope the majority leader reconsiders his decision to deny an 
opportunity for a full debate and vote on these constructive 
suggestions. None of these are nongermane. All of these are directly on 
point and would actually help improve the underlying legislation and 
actually do something about the underlying symptom that necessitates in 
some people's minds this long-term extension of unemployment benefits.
  We are not helping people out by continuing to pay unemployment 
benefits for 2 years and then leaving them hanging without the skills 
they need in order to reestablish themselves in the workforce. 
Unfortunately, the only conclusion I could draw is if the majority 
leader is not interested in having an honest and open debate about how 
do we solve the problems, then something else must be driving his 
agenda. I think we should get back to the day when collectively we were 
more concerned about solving problems than trying to beat on an issue 
and gain political advantage, but that seems to be the road we are 
headed down based on the majority leader's decision not to allow any 
votes on amendments.
  Mr. President, I yield the floor and suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. SESSIONS. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.


                      Remembering Jeremiah Denton

  Mr. SESSIONS. Mr. President, I rise to mourn the passage of a friend 
and to pay tribute to a remarkable man. Jeremiah Denton once served his 
country as a pilot, a prisoner of war, a rear admiral in the Navy, and 
a Senator of the United States. He passed away Friday morning at the 
age of 89, having been active until near the end.
  From time to time men and women are born into this world who are made 
of something special, individuals who seem to have an unlimited 
reservoir of strength and courage, who are made of sterner stuff. These 
people carry themselves with grace and dignity even as the world's 
weight rests upon their shoulders. Jeremiah Denton was such a man.
  A proud son of Mobile, AL, he attended local Spring Hill College and 
the local Catholic schools and McGill-Toolen in Mobile, and he 
graduated later from the U.S. Naval Academy, becoming a pilot and 
commander. What happened next would etch his name into the annals of 
American history.
  On July 18, 1965, Denton led a squadron of 28 jets on a bombing raid 
when he was shot down over North Vietnam. It was his 12th flight. 
Captured by the North Vietnamese, he would be a captive in prison camps 
for the next 7 years and 7 months. During his time as a prisoner of 
war, he endured virtually constant and excruciating torture. He was 
held captive at prisons the POWs called Hanoi Hilton, the zoo, and 
Alcatraz. He endured merciless beatings as well as solitary confinement 
for 4 years.
  As a senior officer, he was a leader among the prisoners and rebelled 
against their brutal efforts to extract propaganda. Denton refused. 
Denton explained in an interview to the New York Times:

       I put out the policy that they were not to succumb to 
     threats, but must stand up and say no. We forced them to be 
     brutal to us.

  Denton wrote a memoir, ``When Hell Was in Session''--which is a 
fabulous book and too little appreciated, really--recounting his time 
as a POW. He describes a torture session in which his captors placed a 
9-foot, cement-filled bar across his shins. He wrote that his captors 
``stood on it and . . . took turns jumping up and down and rolling it 
across my legs. Then they lifted my arms behind my back by the cuffs, 
raising the top part of my body off the floor and dragging me around 
and around. This went on for hours . . . They were in a frenzy 
alternating the treatment to increase the pain until I was unable to 
control myself. I began crying hysterically, blood and tears mingling 
and running down my cheeks.''
  In May 1966, Denton would defy and outsmart his Communist captors and 
display to the whole world the depth of American courage and ingenuity. 
His captors interrogated Denton for a propaganda interview. While 
answering their questions at this interview, filmed by a Japanese film 
company, Denton was simultaneously and repeatedly blinking out a 
message, letter by letter, in Morse code. The message was ``torture.'' 
It was the first official message informing Americans and the world 
that American POWs were being tortured by the North Vietnamese.
  During the interview, he further displayed his unshakeable resolve by 
boldly declaring to his captors:

       Whatever the position of my government is, I support it 
     fully . . . I am a member of that government, and it is my 
     job to support it, and I will as long as I live.

  North Vietnam's most ruthless interrogators couldn't break the will 
of this rock-ribbed American and Alabama native.
  More than 7 long years later, on February 12, 1973, Denton would be 
freed as part of ``Operation Homecoming'' following the signing of the 
Paris Peace Accords. He was the senior officer of the first planeload 
of released POWs at Clark Air Base in the Philippines. Denton brought 
tears to the eyes of the entire Nation at that moment as he walked from 
the plane. It was reported that he wasn't told to make any official 
remarks or make a speech, but he got off the plane and these were his 
powerful words:

       We are honored to have had the opportunity to serve our 
     country under difficult circumstances. We are profoundly 
     grateful to our commander-in-chief and to our nation for this 
     day. God bless America.

  Millions of Americans remember that day.
  Denton earned the Navy Cross, the Defense Distinguished Service 
Medal, the Navy Distinguished Service Medal, three Silver Stars, the 
Distinguished Flying Cross, five Bronze Stars, two Air Medals, two 
Purple Hearts, and numerous other campaign awards. He rose to the rank 
of rear admiral and retired from the Navy in 1977.
  In 1980 the proud and grateful State of Alabama would send our native 
son to the U.S. Senate. A man of deep faith, Denton believed in the 
dignity of public service and the selflessness required of those of us 
who serve. He believed that and he demonstrated it in his life.
  He fought alongside Ronald Reagan to rebuild America's defenses and 
to fight the spread of communism and to help bring about the end of the 
Cold War. He was a firm believer in peace through strength. President 
Reagan recognized Senator Denton during his 1982 State of the Union 
Address. Many remember this. President Reagan said:

       We don't have to turn to our history books for heroes. They 
     are all around us. One who sits among you here tonight 
     epitomizes that heroism at the end of the longest 
     imprisonment ever inflicted on men of our armed forces. Who 
     will ever forget that night when we waited for the television 
     to bring us the scene of that first plane landing at Clark 
     Field in the Philippines, bringing our POWs home? The plane 
     door opened and Jeremiah Denton came slowly down the ramp. He 
     caught sight of our flag, saluted, and said, ``God bless 
     America.'' Then he thanked us for bringing him home.

  So said Ronald Reagan.
  I had the privilege of getting to know Jeremiah Denton. He was a very 
special man. His word was his bond and his loyalty was unshakeable. He 
was modest. While he was a fierce advocate for his profound beliefs, it 
was never about him. In fact, he was very uncomfortable with the term 
``hero'' being applied to him. His comeback was always: ``We were only 
doing our duty.''
  They said, after his time in Communist prison, that he was out of

[[Page S1843]]

touch; he didn't know the 1960s had occurred. Perhaps so. In fact, it 
was so. In plain fact much had occurred while he was in prison and 
being tortured. It was, among other things, a culturally momentous 
time. Many of those changes he did not like. He said so in plain 
language. He didn't like the surge of crime and drugs. He believed in 
loyalty to one's spouse. He opposed abortion. He lamented the 
consistent weakening of family bonds, sexual promiscuity, the decline 
in decency. He cared enough to speak out and again give of himself for 
his faith and his country.
  He represented the best America has to offer. His grit and bravery 
shined through from his dark prison cell deep in Vietnam, and it lit up 
the world. He loved his country. He loved his God. He loved his family.
  In 1996, when I was considering running for the U.S. Senate, I sought 
his counsel. He graciously agreed to come by my house in Mobile. It was 
a very valuable discussion. Near the end, we talked of his service. He 
told me a story--and I think it may be appropriate to tell it now--of 
his time in prison that he had not put in his fine book. After 
President Nixon's bombing and strong military action had brought the 
North Vietnamese to the conference table, Denton was firmly of the 
belief that the Vietnamese were defeated and they knew they were 
defeated. Concerned over possible war crime trials, one of the prison 
officials demanded that Denton tell them all what he would say to the 
world about his treatment if he were to be released. Senator Denton 
sought to avoid the question, saying: Why are you asking me? I am not 
the senior officer in the camp.

  But they pressed him again and again, and he kept saying: Why me? I 
am not the senior official.
  Finally, the prison official looked at him and said: ``Because you 
are incredible, Denton.''
  That is the flat truth. He was incredible.
  When he told the world and his captors during that ``show'' press 
conference before the Japanese television where he blinked the word 
``torture'' that ``whatever the position of my government is, I support 
it fully . . . I am a member of that government, and it is my job to 
support it, and I will as long as I live,'' it was a moment of great 
courage, historical significance, and fidelity to duty that few in this 
Nation would be able to match. He knew the captors would not like it, 
and they did not like it. They beat him brutally for the disrespect he 
showed by telling that truth, and they even did so before they knew he 
had blinked out ``torture.''
  His family was his life. He was married to the late Kathryn Jane 
Maury for 61 years, with whom he had seven children. He is survived by 
his second wife Mary Belle Bordone and his children: Jeremiah, William, 
Donald, James, Michael, Madeleine Doak, and Mary Lewis.
  The entire Senate sends our prayers to his loved ones, and we send 
our promise that Jeremiah Denton will not be forgotten.
  Mr. President, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana.
  Mr. TESTER. Mr. President, every Senator in this body represents 
smalltown America. There are small towns across this country, from 
Connecticut, to Texas, to small towns in my State of Montana. In fact, 
I grew up and still live outside one of those small towns--a town by 
the name of Big Sandy, MT, which is home to 600 people. There are no 
stoplights. The high school has about 60 students.
  What makes America great is that we believe and we cherish the idea 
that whether a person grows up in a town such as Big Sandy or a town as 
big as New York City, a person gets a fair shot in life. That fair shot 
includes the basic freedoms we enjoy as Americans. It includes the 
right to a good education. It includes the right to high-quality, 
affordable health care no matter where we live.
  As a resident of Big Sandy and as a Senator from Montana, it is my 
job to not only represent the entirety of America but to point out when 
our Nation is not living up to its ideals when it comes to rural 
America. Right now Washington is tying the hands of rural hospitals and 
smalltown physicians and threatening the health care of Americans in 
all of rural America.
  The bill we are voting on tonight is a good and important bill. It 
prevents a 24-percent reimbursement cut to physicians under Medicare 
and TRICARE.
  Many folks don't realize that this bill affects retired military and 
National Guardsmen who have bought into TRICARE. This bill is 
critically important to them as well.
  Above all, it makes sure that doctors can keep treating patients and 
that folks can still keep getting emergency services. It may be a 
temporary solution and one we have reached too many times, but it is a 
necessary solution to keep our health care system working.
  I appreciate Leader Reid bringing it to the floor. However, this bill 
could be stronger, especially for folks in rural America. I pushed to 
include two provisions in the bill to strengthen rural health care, but 
despite my best efforts, they are not going to be a part of the measure 
we vote on this evening.
  The first provision, which I introduced with Senator Roberts, removes 
the requirement that physicians at critical access hospitals certify 
that a patient will be discharged or transferred in less than 96 hours 
in order for that hospital to be reimbursed for services.
  Critical access hospitals are treatment centers in rural areas that 
have no more than 25 inpatient beds. They play a vital role in 
providing quality, affordable health care in rural and frontier 
communities across this country. Without them, folks would have to 
travel long distances to get care, and many would not get treatment at 
all.
  But imagine being a rural physician and having to determine exactly 
how long a patient will stay as they are admitted. What if the patient 
develops a secondary condition such as pneumonia? You would have to 
decide whether to discharge the patient, keep them in and risk losing 
reimbursement, or transfer them to another facility at cost.
  Now, how is that good health care? How is that fair to rural America?
  Hospitals should not have to choose between caring for their patients 
and getting paid. This is a choice no one should have to make, and it 
is certainly not one the government should be forcing on rural 
physicians who already have their hands full.
  The second provision, which Senator Moran and I introduced, prevents 
the Centers for Medicare and Medicaid Services from enforcing a new 
rule that requires direct physician supervision of outpatient 
therapeutic services--such as drug infusions--at critical access 
hospitals and other small hospitals.
  If this rule is enforced, it will severely limit the ability of rural 
Americans to get much-needed care in their local communities, where the 
community's one physician may be out of town when the call comes in.
  Should a patient be denied basic blood work because the doctor is not 
available?
  When folks in small towns get sick, the last thing they need is the 
added burden of traveling to another town to get the care they need. 
That is why Senator Moran and I introduced this bill, because 
Washington's one-size-fits-all solutions sometimes just simply do not 
work for rural America.
  Our bill passed the Senate, but there is no companion bill in the 
House of Representatives. So we sought to include it in tonight's fix. 
Despite the fact that there is no stated opposition--and that both of 
these bills will not cost the American taxpayer one dime--we were 
unsuccessful in our efforts.
  I am not asking for much. These two bills are widely supported. They 
are bipartisan, and they will not add to the deficit. And they offer 
much-needed flexibility for rural hospitals seeking to provide high-
quality health care while making ends meet.
  I know Senator Wyden supports them. So does Senator Hatch. I 
appreciate their support. But the House of Representatives, for 
whatever reason, chose to leave these important proposals out. They are 
exactly the kind of bills we should be approving--bills that offer 
support for the thousands of hospitals that provide critical care 
across rural America, hospitals that should not have to have their 
hands tied by regulations that work better in urban communities. We 
should be making sure they have the flexibility they need to meet the 
needs of their communities.

[[Page S1844]]

  Mr. President, if you or I need emergency care here in the Senate, 
there are multiple large hospitals nearby where we can get the 
treatment we need. But that is not the case in rural America. Distances 
in rural America are measured not in city blocks but in miles. We need 
to make sure the regulations coming out of the Department of Health and 
Human Services reflect that.
  Montanans elected me to bring a little more common sense to 
Washington. Often this is not an easy job. But these are two 
straightforward, commonsense provisions to prove to Montanans that 
politicians in Washington get it and they get their concerns. And we 
hope that all Americans get a fair shot at the opportunities promised 
to us, regardless of their ZIP Code. I will keep fighting for these 
provisions and other measures that strengthen and support rural 
America.
  With that, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Oregon.
  Mr. WYDEN. Mr. President, as the new chairman of the Senate Finance 
Committee--16 working days on the job--it is humbling to be parachuted 
late into the issue of reimbursing doctors for Medicare services, and I 
intend to be brief here at the outset of this debate.
  All sides agree that the current system for paying doctors, known as 
the SGR, does not work well for seniors, the many gifted physicians who 
serve them, or taxpayers. Devised in 1997, the SGR sets an annual cost 
target for Medicare physician payments, and it is honored more in the 
breach than in the observance. When the SGR is not met, the Congress 
says that is OK, we will just apply a patch and we will punt. Patch it 
up and let that SGR limp along, just as it has year after year after 
year.
  Mr. President and colleagues, there have now been 16 of these 
patches--16--and every Senator who I talk to says that just defies 
common sense and it seems bizarre even by Beltway standards. The cost 
of the patches now resembles the cost of the full repeal.
  To his great credit, the majority leader, Senator Reid, has 
repeatedly said his first choice for dealing with this issue is to 
finally repeal the SGR. Now is the ideal time for repealing SGR. The 
cost of full repeal is far less than anticipated. Thoughtful, 
bipartisan work has been done in the House and the Senate on repeal and 
replace, and leading advocates for seniors and their doctors want to 
replace the status quo with real reform.
  So as an alternative to the flawed status quo--an SGR patch No. 17--
this afternoon I will make two unanimous consent requests so that the 
Senate is allowed to have a choice; specifically, a vote on a proposal 
to permanently repeal and replace the SGR and also to fund the health 
care extenders.
  I will wrap up by briefly describing this proposal. Its essence is to 
close two chapters of Federal budget fiction. Since the SGR is just 
pretending that Congress will hold the line on Medicare spending, I 
believe it is time to end this fiction and wipe SGR off the books. And 
for balance, I am going to propose ending another piece of budget 
fiction, specifically the Overseas Contingency Operations, known as 
OCO, and the spending on wars that are winding down. This too is 
fiction.
  As former Republican Senator Jon Kyl said--a conservative by 
anybody's calculation--during a previous SGR debate, let's use war 
savings for one last time to wipe out the debt Congress has built up by 
overriding reductions in payments to doctors, and from that point on 
war savings would only be used for defense.
  So there you have my proposal: truth in budgeting all around. Wipe 
the slate clean on Medicare so you can support seniors and their 
doctors and move forward with real reforms along the bipartisan lines 
the House and Senate have already agreed to.
  I would add that if Congress took the action I just proposed, it 
could go farther and address the health extenders. Unlike the SGR, 
these are real programs helping, for example, vulnerable low-income 
seniors, rural communities, and seniors who need a variety of 
therapies. Each one of those has strong bipartisan support.
  This, too, could be addressed in a fiscally responsible manner. A big 
chunk of the cost of 10 years' worth of these extenders could be 
addressed with the savings of the 1-year patch.
  So here is my closing: A lot of good work has gone into a bipartisan, 
bicameral reform plan that finally repeals and replaces the SGR. I 
would just say to my colleagues, doesn't that deserve a vote? If my 
unanimous consent request is accepted, we would have that vote.
  At this time, Mr. President, I ask unanimous consent that 
notwithstanding the previous order with respect to H.R. 4302, following 
disposition of the Owens nomination, when the Senate resumes 
legislative session, the Senate proceed to the consideration of 
Calendar No. 336, S. 2157; that following the reporting of the bill, 
the bill be read a third time and the Senate proceed to vote on passage 
of the bill with no intervening action or debate; and that upon 
disposition of the bill, the Senate resume consideration of H.R. 4302, 
as provided under the previous order.
  The ACTING PRESIDENT pro tempore. Is there objection?
  The Senator from Alabama.
  Mr. SESSIONS. Mr. President, reserving the right to object, I want to 
express my appreciation to Senator Wyden for his leadership. He is 
going to do a great job as chairman of the very important Finance 
Committee. He is active in all the issues before our Senate. But, 
regrettably, a number of Members on this side object to proceeding with 
his legislation at this point.
  I would note that budget experts tell us that paying for this through 
OCO is the mother of all gimmicks. I just spoke about the passing of 
Senator Jeremiah Denton, who was a prisoner of war in Vietnam. We could 
use the savings from the Vietnam war that we are not spending today to 
pay for this bill.
  So I would object, Mr. President. Hopefully, we can figure out 
another way to make this happen because Senator Wyden is correct, it is 
time to get a permanent fix of this matter done.
  I would ask consent that S. 2122, Calendar No. 330, be proceeded to 
for immediate consideration. It would repeal the Medicare sustainable 
growth rate offset by repealing the ObamaCare individual mandate. I ask 
consent that the bill be read a third time and passed, the motion to 
reconsider be laid upon the table.
  The ACTING PRESIDENT pro tempore. The unanimous consent request from 
the Senator from Oregon is on the table. Is there an objection?
  Mr. SESSIONS. I did object, yes.
  The ACTING PRESIDENT pro tempore. Objection is heard.
  Mr. SESSIONS. Mr. President, I ask unanimous consent that the Senate 
proceed to the immediate consideration of Calendar No. 330, S. 2122, a 
bill to repeal the Medicare sustainable growth rate offset by repealing 
the ObamaCare individual mandate. This is proposed by Senators Hatch 
and McConnell and Cornyn. I ask unanimous consent that the bill be read 
a third time and passed, the motion to reconsider be considered made 
and laid upon the table.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Mr. WYDEN. I object, Mr. President.
  The ACTING PRESIDENT pro tempore. Objection is heard.
  The Senator from Alabama.
  Mr. SESSIONS. Mr. President, I thank the Senator from Oregon for his 
leadership and hopefully something can be worked out on this because it 
is important. But it is frustrating that there is no intention, it 
appears, to allow this provision, this fix to be brought up. Therefore, 
without that kind of consent, I think it is unlikely we will get a 
unanimous consent to move forward with Senator Wyden's fix.
  The ACTING PRESIDENT pro tempore. The Senator from Oregon.
  Mr. WYDEN. Mr. President, before my friend from Alabama leaves the 
floor--just to highlight where we are--I think he knows how strongly I 
feel about always trying to tackle these issues in a bipartisan 
fashion. I would just assure the Senator from Alabama, the reason we 
took as our underlying repeal-and-replace bill the good work that was 
done by Senator Hatch and Chairman Camp and Chairman Upton is I felt 
that extended the olive branch in trying to bring the parties together. 
I intend to do that consistently on the Finance Committee--pretty much 
just

[[Page S1845]]

the way I did when I supported George W. Bush on Part D of Medicare.
  The challenge, of course, here is that this would be the 51st attempt 
to essentially try to make changes in the ACA that would end up 
particularly shifting costs to so many vulnerable people.
  It seems to me, particularly today as we have thousands and thousands 
of people still trying to sign up--I noticed the Wall Street Journal, 
Saturday, stated that the CBO said the original target for the 
Affordable Care Act had been met. I think it would be particularly 
unfortunate to go forward with what would be the 51st effort to try the 
same kind of approach that particularly would cause so much cost 
shifting in American health care onto the books of a lot of folks who 
are already walking an economic tightrope.
  I know a number of my colleagues want to speak. As the manager of the 
time, it is my intention to try to alternate with colleagues of various 
points of view with respect to this issue. I am sure that will be done 
as well on the other side.
  I note my friend from Virginia on the floor. He is going to be the 
new chairman of the Senate Finance Subcommittee on Fiscal 
Responsibility. I think he brings extraordinarily important credentials 
to this job. His support of the kind of approach I have advocated this 
afternoon highlights that this will have support in both political 
parties from Members who have strong credentials in terms of promoting 
fiscal responsibility.
  I would yield to him and look forward to my colleague's remarks.
  The ACTING PRESIDENT pro tempore. The Senator from Virginia.
  Mr. WARNER. Mr. President, first of all, I thank the chairman of the 
Finance Committee for his efforts in this endeavor. I am disappointed 
there was an unwillingness to at least have a vote on this important 
issue. I have been a very lucky individual. I have had the opportunity 
to have a career in business, and I have had a career as a Governor. In 
each of those cases, I had to learn business practices and accounting 
practices. Business accounting practices are different than government 
accounting practices. State accounting practices are somewhat different 
as well.
  But I have to tell you, what takes the cake is what passes for 
rational accounting and scoring practices in the Federal Government and 
how we maintain these fictions about what are costs, what are expenses 
in a way where the vast majority of Americans do not have the slightest 
idea what we are talking about: SGR, OCO, terms we throw around in this 
body that have no relationship to the bottom line but prevent us from 
taking action to at least start the process of getting our balance 
sheet right, a balance sheet that right now is $17 trillion in debt, 
that goes up 4 billion a night.
  The chairman of the Finance Committee outlined very well how this 
process came to be, the sustainable growth rate, where Congress 17 
years ago said they saw at that point that the cost of Medicare would 
rise and the cost of our entitlement programs was rising. They put in 
place at that point what they thought was a rational solution to slowly 
slow the rate of growth.
  The challenge was Congress immediately punted. As opposed to 
resolving it at that point, we have maintained this legal fiction and 
this accounting fiction that no one under any kind of traditional 
standards of accounting would accept, where we built in this cost 
increase, and then each year we come back and so-call patch it.
  Each year we go through a fire drill where lobbyists across town 
harangue and harass Members of both parties on a universal basis and 
say: Oh, my gosh. We cannot allow this to happen. Hospitals and doctors 
who should be spending time providing health care or finding cheaper 
and better ways to deliver health care storm the halls of the Capitol 
to make sure we do not provide what would now be an unsustainable cut 
in their reimbursement rates.
  But it appears to me we are now about to go, for the 17th time, one 
more year on a short-term patch and will one more time kick this can 
down the road. What we are avoiding, if we take this vote this 
afternoon and simply patch over an effort that was brought over from 
the House, an effort in the House that I would remind my colleagues 
never came to a rollcall vote, we will once again avoid the opportunity 
to start to, in effect, clear our balance sheet, to make the size of 
our debt and deficit--and for those of us who have been involved in 
this issue, to go ahead and get rid of some of the budgetary fakery 
that quite honestly makes so many of our other efforts that may be 
legitimate seem illegitimate because we cannot even clean up our books.
  The chairman of the Finance Committee went through how this SGR was 
created in 1997 and how we have gone through annual patches. It is 
remarkable that the total cost of these patches actually exceeds--what 
we have already spent exceeds the cost of repeal. The repeal of SGR at 
this point is roughly $135 billion. Based upon previous budget 
estimates, this is the year to take this action.
  What has been the challenge in the past, while there has been 
agreement--we heard from the Senator from Alabama, and others will come 
and bemoan the fact that SGR is a fakery, SGR is budget gimmickry. We 
have this action that is taken on every year, where doctors, hospitals, 
others storm the Congress and say please do not do this, and then at 
the eleventh hour we extend.
  What has avoided opportunities in the past to get rid of this issue 
is that there has not been a solution, not been a bipartisan solution. 
But this year, due to the good work of the chairman, the ranking member 
of the Finance Committee and their equivalents in the House, there is 
agreement on what a replacement to the SGR would look like. We would 
move to a system that would actually fix the problem but also improve 
the quality of service covered under Medicare.
  We would move to a payment system which would reward doctors for 
focusing on providing high-quality care. Doctors would actually be 
rewarded for talking to each other, to make sure tests and services are 
not unnecessarily duplicated. Doctors would be rewarded for ensuring 
patients have access to care when they need it, such as same-day 
appointments. Doctors would be rewarded for spending more time with 
patients and genuinely talking about the patient's priorities and 
concerns rather than running off to their next appointment.
  These are all goals--regardless of what some of our colleagues may 
feel about the Affordable Care Act, these are all goals that almost all 
of us would agree would actually improve the quality of health care in 
America, and for Medicare start to help drive that cost curve back in 
the right direction.
  If we would act on this bipartisan solution, we could make a real 
demonstration, even in an election year, that Congress is actually 
working together to solve the problem.
  The chairman of the Finance Committee noted that in the 5 years I 
have had the honor of representing Virginia, there is no issue I have 
been more passionate about, involved with, than trying to find that 
common ground around our debt and deficit, sometimes to the chagrin of 
my own colleagues on this side of the aisle.
  I believe getting our fiscal house in order is absolutely the top 
priority that this Congress and our Nation face. I believe failure to 
do that will squeeze out any investment in education, infrastructure, 
military, whatever our other priorities are. Part of that is getting 
our entitlement costs under control. But if we are going to get our 
entitlement costs under control, we have to eliminate the budget 
gimmicks and fakery that now are part of the process.
  The primary one on the entitlement side is the SGR. We have a 
remarkable opportunity to get rid of this peace of budget fakery, to 
clear the books, to put in place a better system. I know there have 
been questions about the cost. I believe the chairman of the Finance 
Committee will soon put up a chart which will quote a periodical that 
does not often say good things about those of us on this side of the 
aisle; that is, the Wall Street Journal, which has called the SGR a 
``bookkeeping gimmick which merely hides Medicare's true cost by moving 
future spending off the balance sheet.''
  Again, we have a chance to get rid of that today. What I think the 
chairman of Finance Committee has offered is we could actually get a 
two-for. We could

[[Page S1846]]

get rid of repealing and replacing the SGR and at the same time 
eliminate another budget gimmickry tool, the OCO account.
  I cannot understand why we would not take advantage of this 
opportunity to start down the path of cleaning up our balance sheet. At 
the end of the day, the actions we take today will not get rid of that 
$17 trillion in debt. It will not bring down our deficit in itself, but 
it will allow future actions to be dealing with an accounting system 
and a budget that is much truer to reality.
  The chairman of the Finance Committee has called this the Medicare 
migraine. I think it is time for this Congress, this Senate, to 
actually take two aspirin, pass this replace and repeal, get rid of 
this migraine, and at the same time show the American people we can act 
in a bipartisan fashion, even in an election year.
  The ACTING PRESIDENT pro tempore. The Senator from Oregon.
  Mr. WYDEN. Mr. President, before he yields the floor, through the 
Chair, I would pose a question to the distinguished Senator from 
Virginia.
  The Senator from Virginia has, as usual, gotten right to the heart of 
the long-term challenge with respect to entitlements. I have always 
tried to describe it as the challenge of protecting the Medicare 
guarantee because what seniors have is a guarantee. It is not something 
that is up for grabs. It is a guarantee. It is inviolate. Protecting 
their guarantee means that in the days ahead we are going to have to 
figure out new ways to hold down costs.
  What I have heard the Senator from Virginia talk about very 
eloquently is one of the key ways to do that is what the Senator from 
Virginia and I have sought to do, which is to start having Medicare--
start having Medicare pay for value rather than just staying with this 
volume-driven fee-for-service system, which largely rewards 
inefficiency. I think it is my sense that the Senator from Virginia 
believes it is very hard to start the kind of real entitlement reform 
we need, where we protect the Medicare guarantee and hold down costs, 
unless we make the kind of approach we are advocating in this repeal-
and-replace strategy with SGR.
  We better get to it, because until we have those changes, we cannot 
begin to get on with another area that the Senator from Virginia feels 
very strongly about; that is, chronic diseases--diabetes, cancer, heart 
disease, and stroke--which consume more than 80 percent of the Medicare 
budget. By my calculation we cannot get on that or any of the 
structural entitlement challenges until we do what the Senator from 
Virginia is talking about: Is that pretty much the way the Senator from 
Virginia sees it?
  The ACTING PRESIDENT pro tempore. The Senator from Virginia.
  Mr. WARNER. Mr. President, I would agree with the comments made by 
the chairman of the Finance Committee. In the repeal-and-replace 
proposal we have laid out ideas that again I think across the aisle 
there is going to be common agreement on. I know we have been joined by 
my good friend the Senator from Oklahoma. No one knows more about 
health care and has been a stronger voice on entitlement reform than 
the Senator from Oklahoma.
  We have spent an awful lot of time wrestling with how we get to that 
common cause. These commonsense reforms that move us closer to quality 
rather than quantity are a first step.
  Also, a first step is trying to relieve the annual or sometimes 
every-6-month fire drill we go through where health care providers 
across the country have to rush to Congress to try to get a patch in 
place, which at the end of the day we know we will put in place. The 
way we put the patch in place more often than not is simply passing 
more cost to the providers in an outyear. This is the kind of budget 
gimmickry that quite honestly we tried to address in our so-called Gang 
of 6 that would have had more constraints. We didn't get it done.
  We have another opportunity today--not to solve the whole problem, 
but by getting rid of SGR, by getting rid of OCO, we are moving two of 
the accounting and gimmickry obstacles, which would help clear the 
decks toward the ultimate debate we are going to have about tax reform 
and about retirement reform. But the value is that by repealing the 
SGR, we would also put in place reforms that move us toward a better 
quality health care system for our seniors.
  I know the consensus and conventional wisdom is that at moments such 
as these we will always punt. We will have a chance this afternoon to 
see whether we will punt one more time or whether we will actually--if 
it takes a few more days--wrestle this to the ground and come up with a 
common cause where we could repeal SGR, replace it with a better 
system, and perhaps at the end of the day get rid of not one but two 
gimmicks that have made our budgeting so much more difficult.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. I would like to spend some time talking about the bill 
that is on the floor.
  I thank my colleagues from Oregon and Virginia. I have enjoyed 
working with them.
  The bill we have on the floor is one of the reasons I am leaving 
Congress at the end of this year. This is why the American people are 
disgusted with us. We are going to put off until tomorrow what we 
should be doing today. We should be fixing this problem instead of 
delaying the problem. I concur a lot with what my colleague from 
Virginia said. But the fact is that there is no courage, there are no 
guts, and there are no intentioned actions to do what is the best thing 
in the long term for this country in this body anymore.
  We have a bill that came to us--and I appreciate the fact that the 
chairman wants to try to fix it. But if they vote for this bill that is 
on the floor today, they are part of the problem. They are not part of 
the solution; they are part of the problem.
  There are four budget points of order that lie against this bill. Why 
in the world would there be four points of order lying against this 
bill? We are only going to vote on one of them. It is because it is a 
sham. It is a lie. The pay-fors aren't true. They are nothing but 
gimmicks. It is corruptible. There is no integrity in what we are 
getting ready to vote on in terms of being truthful with the American 
public and in terms of being truthful with the people who are providing 
the care for Medicare patients.
  I have a little bit of experience--25 years of practicing medicine. I 
can tell you what is wrong with the payment system. We have a payment 
system both from the insurance industry and from Medicare and Medicaid 
that says: See as many patients as you can if you want to pay your 
overhead because we are going to pay you based upon a code rather than 
how much time you spend with a patient.
  The first thing a doctor is taught in medical school is sit down and 
listen to the patient. If we spend time with the patient, the patient 
will tell us what is wrong with them. We know that is true because we 
have two of the sets of data now--both on the concierge medicine that 
has come up in the past few years as well as what we have seen in one 
of the great HMOs on the west coast. They order 62 percent fewer tests 
when they are listening to the patient.
  One of the biggest costs for Medicare, one of the biggest wastes for 
Medicare is tests. Why do doctors order tests? Because they didn't 
spend the time figuring out what is really wrong with the patient, so 
they order a bunch of tests to try to help them; whereas, if they had 
spent an additional 15 or 30 minutes with the patient, most of those 
tests--and most are not without risk--would never have been performed.
  We have the Senate doing what we usually do: We are putting this off 
until tomorrow when we can actually fix the real problem now.
  It comes to another principle of medicine. The principle of medicine 
is that we don't treat symptoms, we treat disease. When we treat the 
disease, the symptoms go away. If we just treat the symptoms, we will 
never find the disease. We will cover up the disease. That is exactly 
what we are doing.
  The SGR was a great idea. It started in 1995 in the Ways and Means 
Committee in the House under former chairman Bill Archer. Had we 
followed it, we would have seen some significant reining in of the 
costs of care and Medicare. But what happened? We cut spending and we 
cut reimbursement rates one time. Instead of responding to the 
political clamor of the provider group, we fixed it--a short-term fix. 
We have been doing that ever since 1999, short-term fixes.

[[Page S1847]]

  We are not fixing this problem today. What we are doing is taking a 
big old can and kicking it down the road. Worse than that, we are not 
even being truthful about what we are doing.
  One of the little gimmicks is to shift $5 billion of sequester from 
2025 to 2024 and say you saved money. But we all know this little red 
area on this side will go over to the other side and we will spend that 
money. Nobody believes it. It is kind of the wink and the nod to the 
American public: Oh, look at us.
  There is no truth, there is no honesty about what we are doing. And 
that is only one. This is the other offset. The sequester was the one I 
just showed. Savings from future Medicare cuts: $2.3 billion. They will 
never occur. If you think they will occur, you obviously think--if they 
will occur, then we should have fixed the real problem, the real 
disease of Medicare today. But we didn't. So the actions will continue 
to be exactly the same. That $2.3 billion will never be materialized 
whatsoever. It is a falsehood--$4.4 billion to Medicaid. It will not 
ever come about. That is in the future, but we will take the money now 
to pay for it.

  In this bill of approximately $20 billion, half of the savings we say 
are there aren't there. Every Member of this body knows that. So when 
they vote for this fix today and vote against the budget point of 
order, what they are saying is: I am dishonest, I am playing the game, 
and I will not stand up for truth so the American people actually know 
what we are doing. I do not believe in transparency. I do not believe 
that we ought to have to live within our means, that we ought to make 
hard choices, just as every American family out there does today.
  Finally, some of this is very unfair to the very people who worked on 
this with the committees because they made some commitments for real 
cuts to them to get a long-term fix. Guess what. The real cuts--the 
portion that is actually paid for--pay for it for only 1 year. So not 
only are we dishonest with the American people, we are dishonest with 
the stakeholders who negotiated this for a 10-year elimination.
  The budget points of order against this bill--just so we know what we 
are talking about, it violates pay-go. Plain and simple, it violates 
pay-go. This bill increases the on-budget deficit. I dare somebody to 
come down to the floor and tell me it does not. It does.
  It violates the Ryan-Murray 2014 congressional Budget Act because it 
violates the top line. Nobody is going to come to the floor and say it 
doesn't. We won't hear one speaker come to the floor and say it doesn't 
violate that. It does. They know it does, but they won't speak the 
truth.
  This bill also spends money in excess of the Finance Committee's 
allocation--another point of order against the Budget Act. Everybody 
knows that is true, but they won't come down and say it doesn't; they 
will just vote for it.
  It also has language in it within the Budget Committee's jurisdiction 
that has not been reported or discharged. So we are totally ignoring 
the process the chairman of the Finance Committee would like to have so 
we can do the expedient political thing to take some pressure away, 
just as we did on the flood insurance bill. It got a little hot in the 
kitchen. Instead of actually cooking the omelet, we threw the eggs in 
the trash can and ran out of the room, and that is exactly what is 
going to happen in the Senate. We are again putting off the hard 
choices.
  Let me tell you why this is important. The Senator from Virginia 
outlined this a little bit. When I came to the Senate, which was 9 
years ago, the individual debt each one of us held on the national debt 
was under $32,000. Today it sits at 54,800-and-some-odd dollars. We can 
kind of get lost in that. What we have to think is this: Well, what is 
my family's obligation for what we haven't paid for in the Federal 
Government?
  Let me tell you what it is. For every family in America, whose 
average income is $53,000 per year--the same as it was in 1988 in terms 
of real dollars; we have gone backward--your obligation is now $1.1 
million per family.
  And we are going to play this game again and we are going to add 
another $10 to $12 billion between now and April? We are going to say 
and claim it doesn't add anything, but we are going to add another $10 
billion so we can get away from the heat, so we can get out of the 
kitchen, so we won't be responsible.
  Which is more responsible--to tell the truth about where we really 
are or to actually profess an untruth to your constituents in this vote 
this evening? Because that is what it is. Mark my words: Every Senator 
who votes for this bill that came out of the House will be telling an 
untruth to the American people. They know it is not paid for. They know 
it violates all sorts of rules in the Senate. They even violated the 
House rules as they passed it--all to meet a deadline?
  To give a little history, we have missed the deadline before on SGR 
fixes. Does it cause additional work for providers, doctors, hospitals, 
and doctors' offices? Yes. Does it provide additional work for CMS? 
Yes. Do we eventually catch up on it? Yes. So what is the hurry? Why 
not really treat the real disease? The real disease is that we have a 
payment system that is not good for patients and is not good for 
providers. We can't fix it over a weekend, but we can fix it. If we 
don't fix it, as the chairman would like to see a long-term fix--I 
don't necessarily agree with everything he wants to do, but I applaud 
his effort to get a long-term fix. If we don't fix it, we don't deserve 
to be in the Senate.
  There will be no credibility left and there will be no legitimacy 
left if we pass this bill. It is all a pack of untruths--untruths to 
the stakeholders, untruths to the American public and, most 
importantly, untruths to the generation coming up that is going to pay 
the bill for our untruths. This isn't an unfixable problem. It is a 
problem that hasn't gotten the attention and the time it needs, and it 
reflects poor leadership of the Congress and the committees. We knew 
this was coming up 1 year ago. The Senator from Oregon can totally be 
forgiven because he wasn't in charge of the Finance Committee until 1 
month ago. But there is no denying the fact this problem was there.

  Doing a patch--and even doing some of what Senator Wyden wants to 
do--won't fix the ultimate problem. Think about the interaction you 
have with your caregiver. The average time in a doctor's office when 
you go in, before you are interrupted by your physician, is now 6 
seconds. You go in, sit down, and the doctor asks: Why are you here 
today? You start to say something, and the first thing you know, you 
get interrupted. Why? Because that physician knows he needs to get to 
the next patient to pay the bills because we are paying bills based on 
CPT cuts rather than paying the physician based on the amount of time 
they spend with the patient, including outcome measures.
  We have a system that is designed to be defrauded and creates 
overutilization. We designed it. We can fix it. Voting for this bill 
doesn't fix anything except a little heat in the kitchen. When we come 
back the next time, the heat is going to be hotter, and hotter, and 
hotter. This bill is a cowardly response to the real problem that we 
have. It is time we quit being cowards.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Before he leaves the floor, I want to say to the Senator 
from Oklahoma, who says--and always with a smile--that he and I 
certainly don't agree on everything in this debate, that the concept of 
what he is talking about--that physicians spend time with their 
patients--is certainly a concept that ought to be incorporated into how 
we proceed in the days ahead.
  The other aspect of this that people ought to focus on, with respect 
to what the Senator from Oklahoma is talking about, is that time that 
the physician spends with the patient in the office presents a pretty 
good chance that some of those discussions they have there in the 
office are going to help keep that patient out of the hospital, and all 
sides ought to see that as a constructive goal.
  So I want my colleague from Oklahoma to know that in the discussions 
he and I have had--and I appreciated the way my colleague said with a 
smile we don't agree on everything--the concept he is talking about 
with respect to doctors and time in the office--is something that ought 
to be incorporated into this, and it is my intention to work with my 
colleague on that.
  Mr. COBURN. I thank the chairman.
  Mr. WYDEN. Mr. President, I want to pick up on another aspect of what 
both

[[Page S1848]]

the Senator from Virginia and the Senator from Oklahoma have talked 
about, and that is that at this rate we have to be concerned that after 
patch 17 there will be patch 18, and after 18 there will be patch 19. I 
am sure there are some young people up in the galleries who are light 
years away from Medicare. In fact, the distinguished Presiding Officer 
of the Senate is a number of years away from the program, and I don't 
want to see him looking at patch 30 or 31 or 32. But the reality is if 
all we do is to take what we have and extend it, we are not going to 
turn this situation around.
  My colleague from Virginia and I started talking about one of the key 
concepts in our repeal and replace strategy, and that is making sure we 
have a hard date--really, for the first time--to start paying for value 
in health care. Repeal and replace has that hard date. This is long, 
long overdo. Until then, in much of our country, we will still have 
volume-driven, fee-for-service medicine still driving health care in 
those communities from one end of the country to another.
  I heard one observer say what they hoped for is that somebody in 
Washington would take a machete to fee-for-service. At a minimum, we 
ought to do what repeal and replace does, which is to reward for the 
first time quality, and ensure the message goes out to every corner of 
the country. I have heard the distinguished Presiding Officer of the 
Senate say with respect to his important health care reform efforts 
that instead of just paying for volume, we should actually pay for 
results, and results mean patients have a higher quality of life. What 
we know, in many instances, is that kind of care also costs less 
because we don't have people sicker and needing more expensive services 
and possibly institutional care.
  So now, while I wait for additional colleagues to come and speak, I 
want to take a few minutes to describe some of the other opportunities 
we are missing out on by not going forward with full repeal and 
replace, as I and Senator Warner and others would like to see.
  In particular, it is very clear that Medicare in 2014 is remarkably 
different than Medicare back when it began in 1965. Medicare in 2014 is 
now dominated by chronic disease. Cancer, diabetes, heart disease, and 
stroke is more than 80 percent of the Medicare spent. I believe we have 
some opportunities for some very important breakthroughs.
  The Senator from Georgia, Mr. Isakson, has joined me in a bipartisan 
bill here--the Better Care, Lower Cost Act. It is bipartisan in the 
other body with Congressman Peter Welch and Congressman Erik Paulsen. 
That would give both parties an opportunity for the first time to 
provide the real financial incentives for the long term to reward the 
kind of coordinated care we are not getting in this country for 
seniors.
  For many seniors, after the free physical they now get under 
Medicare, their care is so fragmented, so poorly coordinated that until 
they land in a hospital emergency room, perhaps with a $1,100 
deductible and can't figure out all the doctors they have seen during 
their odyssey through chronic care treatment, we have virtually no 
system that responsibly manages and is accountable for that senior's 
care.
  In repeal and replace, we take the first steps toward building a 
chronic care policy for our country. We take the chronic special needs 
plans--what are called the CSNPs--that haven't worked out as hoped and 
initiate reforms for those particular plans to ensure that all of the 
individuals who are part of that program would, for the first time, 
have an individual care plan. That is something many seniors--certainly 
a majority of seniors--lack, particularly if they are part of 
traditional fee-for-service medicine. They don't have an individual 
care plan. They might have two or more kinds of chronic conditions.

  A senior might think they can manage their own medicines and manage 
their own nutrition, but there would be an alternative. That would be 
what Senator Isakson and I have talked about for the long term and what 
we would begin with in a true repeal and replace program for SGR. With 
SGR, we would start finally looking at those chronic care patients in a 
way that ensured they got coordinated care from the first time they saw 
a physician, who, under our approach for the long term, would have a 
pharmacist and a physician assistant and maybe a nurse. They would be 
able to have one person accountable for their care.
  The irony is that all over the country there are programs that are 
now doing this and reaping dramatic savings. For example, in rural 
Pennsylvania there is a particularly promising program where the 
savings have exceeded more than 20 percent on some of the sickest 
patients with the kind of approach that Senator Isakson and I are 
advocating for the long term, and which we would at least begin with 
these chronic special needs patients under full repeal and replace of 
the SGR.
  Now, I want to close with one other point before I yield the floor to 
colleagues. The full repeal and replace of Medicare would also contain 
an idea that Senator Grassley and I have worked on for over 3 years, 
which is to open the Medicare database. The Medicare database is really 
a treasure trove of the most useful information about Medicare claims 
and payments around this country. It holds the record of all payments 
from taxpayers to physicians and other providers for seniors' health 
care.
  Right now, access to this Medicare database is very limited. If the 
public or seniors or others want to get access to this information, 
they have to wade through the bureaucracy, and there are simply very 
substantial obstacles. We know this kind of information can often 
produce better quality for lower prices because providers who do well 
when that information gets out will see they are rewarded for their 
work, and those that are not measuring up to those standards will 
either have to change their practices or simply find it hard to keep 
their doors open. The markets work best when information is transparent 
for all parties.
  Today, most patients lack any comparative information and usually 
don't find out the cost of their care until after the fact, if at all. 
So Senator Grassley and I have proposed there be a free and searchable 
database, one that would allow seniors to find and choose doctors and 
other health care professionals enrolled in the Medicare program, 
adding the actual services that are performed and what price Medicare 
pays for those services.
  Americans would finally be able to compare what Medicare pays for 
particular services in different parts of the country. Opening the 
Medicare claims database in this way would help us hold down health 
care costs, would also improve the quality of Medicare services, be a 
tool in fighting fraud, and would be useful in helping individuals with 
private health plans--private plans, HSAs and employer-based insurance.
  What is going to happen there is, if you have an employer plan in 
Hartford, CT, or an HSA in Connecticut, the first thing you are going 
to say is, this is what Medicare pays for a particular service; why 
can't I, with my employer plan or my HSA have the same price? If I am 
not getting it, that probably means I am getting less pay, and I would 
rather see health care costs held down so I could get more in my 
paycheck.
  So opening the record--from a quality standpoint--of Medicare-paid 
services would be a very powerful tool for measuring hospital and 
doctor performance. The claims data, with full protection of patient 
privacy, would open how doctors and hospitals are treating patients. It 
would also provide a full accounting of areas which lack access to 
doctors, specialists, treatment, and procedures. Making this 
information readily available would also allow doctors to collaborate 
on improved care management, and make sure the highest quality services 
are delivered to patients at lower costs.

  Finally, the transparency we would get from the efforts Senator 
Grassley and I have teamed up on, which was part of the full repeal-
and-replace strategy, would help us have a powerful new tool against 
fraud and waste.
  We look at the Medicare Program. The Wall Street Journal and the 
Center for Public Integrity have been able to, even with limited access 
to Medicare claims data, look at that information and expose through a 
series of articles how doctors and medical practitioners game Medicare 
to increase their profits. If we made the system

[[Page S1849]]

more transparent, as Senator Grassley and I have sought to do and is in 
the full repeal-and-replace proposal, we would have a significant new 
tool to root out those--and they are a relatively small number, 
fortunately--who truly fleece seniors and taxpayers and allow us to get 
more value for the Medicare dollars.
  In 2012 the Medicare Program cost about $580 billion. In a few years, 
given the demographics and technology, this bill is going to go over $1 
trillion.
  Often when I go to a high school and meet with young people--as I am 
sure does the distinguished Presiding Officer--16-, 17-, and 18-year-
olds, we talk about matters which concern them, student scholarships, 
parks, transportation. Toward the end of the meeting I often say: So 
you all are 16, 17, and 18. My guess is, given your age, you probably 
tweet your friends when you get up in the morning about Medicare.
  These students smile: Well, there is another person from Washington, 
DC, who doesn't get it.
  I kid with them a little bit. Finally, I say: I just want you to know 
I am kidding, but not really. Because if we don't figure out how to 
protect the Medicare guarantee and hold down the costs for all you 
students who care about scholarships and parks and roads and the like, 
guess what. There is not going to be any money for the concerns which 
are first and foremost to you.
  At this point, of course, the students jump right in, and they want 
to know about preventive medicine and how to root out waste and some of 
the things we are talking about. But we can't get to a lot of those 
important Medicare reform issues which Senator Warner articulated so 
well when he began his remarks if we can't get full repeal-and-replace 
of the badly flawed Medicare SGR Program.
  I have spent a few minutes talking about how Senator Isakson has an 
approach which is bipartisan in both the Senate and the House on how to 
deal with chronic disease; I have talked about opening the Medicare 
database which is in full Medicare repeal and replace; I have talked 
about some broad reforms. Of course, at the center is paying for value, 
which is in full repeal and replace starting in 2018, and we may not 
get for a while if the Congress just keeps reupping from the 17th patch 
to 18th patch to the 19th patch.
  So what we are going to have to do here in this body--and I know the 
distinguished Presiding Officer has a great interest in the question 
and the budget and the future particularly of entitlement costs, which 
I would say puts the Medicare guarantee and holding down costs front 
and center--we are going to have to speed up, we are going to have to 
accelerate the drive to actually get full repeal and replace, rather 
than patch 17, patch 18, patch 19, patch 20, and up. My view is we 
ought to be doing it now.
  I recognize the objection from the other side. But I have talked to a 
lot of Senators over the last 3 days of both political parties, and I 
think there is a growing awareness that simply extending what we 
already have and punting on the need to fix the urgent structural 
problems with what we have--which is what some Senators and House 
Members sought to do--can't be ducked much longer.
  Mr. President, I reserve the remainder of my time for closing.
  I yield the floor and I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. King). The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. KAINE. Mr. President, I would ask unanimous consent that the 
quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Virginia.


                            Afghan Democracy

  Mr. KAINE. Mr. President, I rise to voice my support for the people 
of Afghanistan who this week on Saturday will be in the midst of a 
Presidential election pursuing the first Democratic transfer of power 
in that nation's history. April 5 will be a momentous day, a 
Presidential election where millions of Afghans will head to the polls 
to determine their destiny by a peaceful means. As we know much is 
going on in the world in Ukraine, Syria, and Iran. It is easy to miss 
this milestone, but it is a milestone I think should have some 
significance to us as Americans.
  Americans should be proud of the role we have played in bringing the 
Afghan people to this point, given the significant sacrifice members of 
our country have made. There have been nearly 2,300 servicemembers who 
have given their lives in Afghanistan--2,299. The United States has 
spent $600 billion in Afghanistan since September of 2011. While we 
cannot gloss over the challenges that remain in Afghanistan today and 
tomorrow, we should remember the progress that has been achieved in 13 
years since the Taliban fell in October of 2001, progress that has been 
made possible because of the sacrifices of American service men and 
women, our diplomats, the American people, and the grit and 
determination of the Afghan people.
  On April 5 Afghans will defy those who seek to intimidate them 
through violence and terrorism because it is a fundamental choice: Does 
Afghanistan want to move forward or go backward to horrific days. The 
ink-stained finger of an Afghan voter will send a far more powerful 
message than any terrorist gun or bomb. I think Afghan men and women 
will be thinking of their children as they vote on Saturday, the 
promise of the next generation as they head to the ballot box. An 
Afghan girl born in October of 2001 when the Taliban fell is now 13 
years old. She has no doubt faced hardship and will continue to, but 
she now has before her unprecedented opportunities.
  Sometimes we get into a little bit of a mode where we say things 
haven't gone well in Afghanistan or the investment of blood, treasure, 
and energy by the United States hasn't made a difference. I wish to put 
on the record 13 very real indicators of a transformation in an 
Afghan's life in the last 13 years.
  No. 1, two-thirds of Afghans today have and are able to use cell 
phones compared to 5 percent before 2001. Before 2001 Taliban-
controlled radio was the only news source in Afghanistan. Today Afghans 
can choose from 75 television stations and 170 radio stations.
  The Afghan national gross domestic product has grown nearly tenfold 
since 2001. One in three Afghans has access to electricity. Kabul 
enjoys a power supply 24 hours a day.
  In 2001 in Afghanistan there were only 30 miles of paved roads, which 
had a direct impact on their economy. Today nearly 10,000 miles of 
paved roads--nearly 300 times the amount in 2001. Over 50 percent of 
the population now has safe drinking water, nearly double from 2004.
  The number of teachers in Afghanistan was only 20,000 in 2001. Today 
it is 175,000, 30 percent of whom are women. Three million Afghan girls 
are enrolled in schools compared to only 5,000 in 2001, a nearly 600-
fold increase. Overall school enrollment in Afghanistan has increased 
to more than 8 million.
  There are 168 female judges across Afghanistan and 68 women members 
of the National Assembly. Eighty-five percent of Afghans now live in 
districts with health care providers. Infant mortality has been reduced 
to 327 per 100,000 live births, which would still be high for the 
United States, but in 2002 that number was 1,600. So it has been 
reduced to one-quarter or one-fifth.
  The number that is the most powerful is this: Afghan women now have 
access to more health care than before. Female life expectancy has 
increased since 2001 from 44 years to 64 years--from 44 years to 64 
years. So just think about what 20 extra years of life is like for a 
woman and then multiply that by every woman and girl in Afghanistan. 
Male life expectancy has improved as well because of improvements in 
infant mortality. This is a significant change, a real transformation 
in Afghan life.
  We cannot discount remaining challenges to combat corruption and 
strengthen civil society and to further advance women's rights. The 
recent attacks by the Taliban on the electoral process at an NGO 
guesthouse in Kabul at the Serena Hotel and over the weekend at the 
Afghan election commission remind us that security is a problem. Our 
condolences go out to the victims. The attacks show a cowardly 
desperation.
  The ballot box represents the largest threat to the Taliban and any 
terrorist affiliate and they are resorting to indiscriminate attacks 
because they know a ballot box and electoral democracy will be their 
demise. By killing Afghans on the threshold of an election, the Taliban 
is only sowing the

[[Page S1850]]

seeds of their own demise. They recognize the tide of history is 
against them.
  A word about the Afghan National Security Forces who are working 
together with the United States and other partners going forward, 
especially on these elections this week: More than 350,000 Afghan 
soldiers and policemen are the security lead now throughout the 
country. They bear the brunt of the casualties of these attacks. More 
than 13,000 Afghan security force members have been killed in the line 
of duty, but they are determined, with the support of our country and 
the training we have provided them and that others have provided them--
they are determined to protect their homeland and they have proven 
capable of securing their homeland. Our servicemembers and diplomats 
have for years trained and assisted, and that training is paying off as 
is shown every day. We also have numerous examples of Afghan 
interpreters who have assisted our servicemembers in that training, and 
we cannot forget them.
  The Afghan forces will not face the challenges of this week, the 
electoral challenge, or the challenges beyond alone. The future of 
Afghanistan is not a military challenge alone. It rests upon security 
throughout civil society, and these elections are a pivotal moment but 
not the only pivotal moment.
  The commitment of the United States to Afghanistan continues. In 2011 
we signed a strategic partnership agreement. We designated Afghanistan 
as a major non-NATO ally of our country. There is a text that is 
complete of a bilateral security agreement outlining our willingness to 
train, advise, and assist in this mission beyond 2014. I am confident 
it will be signed once the new government takes place.
  One of the reasons I am confident is that all of the candidates for 
the President of Afghanistan are engaged in a civil debate, and they 
are being asked what they think about the role of the United States, 
and they are all committed to the United States playing this new role 
as they transition their democracy with this peaceful transfer of 
power.
  Finally, a word about what is at stake because it is not just about 
the statistic, it is also and most importantly about individual lives.
  Just 3 months ago in January, Colonel Jamila Bayaz, a 55-year-old 
mother of five, became the first woman to be appointed a police chief 
in Afghanistan. At her promotion ceremony she said she would not have 
achieved her position but for the efforts of the United States and the 
international community.
  In a letter that same month to President Obama, over three dozen 
civil society Afghan leaders stated as follows:

       Over the coming years, Afghanistan will be completing its 
     political and security transitions as the foundation for the 
     future that we seek. It is our sincere hope that the people 
     of the United States, who were with us during difficult 
     years, will remain with us as we complete the challenging 
     transition period and become more self-reliant.

  Hengama Anwari is the woman who is the current head of the Afghan 
human rights commission. Last week she stated: ``10 years is only a 
drop in the ocean in the process of changing a society.'' But Ms. 
Anwari is still hopeful about the future of her country and is 
relentless in her effort to advance women's rights.
  When George Washington stepped down as President during America's 
first Democratic transition, it was a pivotal moment for our young 
Republic. This transition, the first peaceful transition in 
Afghanistan's history, is equally pivotal. We stand shoulder to 
shoulder with Afghans, but this is an Afghan moment. Every candidate, 
every soldier, every election monitor, every citizen must do their part 
to ensure the success of this transition.
  Finally, as the Afghans transition, so do we--so do we. The 
congressional action that authorized our military presence in 
Afghanistan was passed in this body on September 14, 2001, nearly 13 
years ago. With our combat mission in Afghanistan coming to an end with 
this election and a peaceful transition, with the transition of 
American military participation to a train, assist, and advise role, 
this 13-year effort is now transitioning to something new that will be 
the subject of that bilateral security agreement.
  We haven't been able to have a welcome home party for all of our 
American service men and women who served in Afghanistan because the 
operation was ongoing. It is my hope this transition in Afghanistan, 
which will also transition our role, will enable us to have one of 
those pivotal expressions of American pride. We have all seen the 
pictures of V-E Day and V-J Day, when the American Republic celebrated 
the end of a period of sacrifice of our service men and women. This is 
a period of sacrifice that has been going on longer than any war in the 
history of this country. It is my hope that while we will continue to 
work together with the Afghans, we may reach a moment where we can 
celebrate, we can acknowledge this transition, and say welcome home and 
thank you to all the American service men and women who along with 
their families have given so much in the last 13 years.
  With that, I yield the floor.


                   Recognition of the Minority Leader

  Mr. McCONNELL. Mr. President, I would ask to proceed on my leader 
time.
  The PRESIDING OFFICER. The Senator has that right. The Republican 
leader is recognized.


                               Final Four

  Mr. McCONNELL. Mr. President, we all know a huge percentage of 
Americans across the country filled out their brackets a couple of 
weeks ago to get ready for March Madness. Now it is down to the final 
four, and once again the University of Kentucky is in the final four. 
It has become something we are quite accustomed to after having won the 
championship at UK in 2012. We kept the championship in our State for 
2013 with the University of Louisville. Now we intend to further 
underscore that the college basketball capital of the world is indeed 
in the Commonwealth, and we look forward to watching in Dallas the 
final four next weekend.


                          ACA Signup Deadline

  Mr. President, today is the normal deadline for most people to sign 
up for ObamaCare, and while one Senator on the other side of the aisle 
said yesterday there is no such thing as ObamaCare, that will come as 
news to millions of our constituents--the millions of Americans facing 
higher premiums, canceled plans, and the loss of doctors and hospitals 
they like as a result of this law.
  ObamaCare is definitely real to middle-class families whom we 
represent. If our friends on the other side want to make the pain of 
this law go away, they can work with us to replace it with smart, 
bipartisan reforms. They are trying to wish away their own ObamaCare 
law or are simply pretending it is not there. That is not going to 
work. The American people deserve a law better than that.


                       Innovation and Opportunity

  We will be having a vigorous debate this week in the Senate about how 
to create jobs and rebuild the middle class. On the one side our good 
friends the Democrats will be offering more of the same. They will 
propose treating the symptoms instead of meaningfully improving the 
prospects of people who are struggling out there.
  On the other side Republicans will be proposing concrete ways to 
break the cycle of unemployment and hopelessness that pervades the 
Obama economy, ideas aimed at helping people reach their true potential 
and build a better life for themselves. The Republican message is all 
about innovation and opportunity and making it easier for more people 
to join the ranks of the middle class. It is about reforming the 
underlying causes of unemployment instead of just perpetually treating 
the symptoms. It is about how we create jobs for the future that will 
allow Americans to do a lot more than simply pay their 
bills. Republicans will offer a series of jobs amendments this week 
that underline our determination to reorient America's economic 
trajectory. We want to lift our country from stagnation to growth, from 
hostility toward enterprise to an embrace of innovation, and from a 
system rigged by government elites for their own benefit to one that 
can actually work for the middle class again.

  Americans will hear two competing agendas this week: on the one hand, 
a tired, government-centered Democratic agenda designed by and for 
ideologues of the left; on the other, a modern, enterprise-oriented 
Republican agenda designed around the hopes and potential of the middle 
class.

[[Page S1851]]

  This is a debate Republicans welcome. It is one we have been waiting 
to have for a very long time, and we hope Washington Democrats will 
actually be serious this time when they say they want to focus on jobs 
because every time they say that, they keep getting distracted and 
pivot to other issues.
  Here is something else we need to expect from the majority: votes on 
amendments for positive reform. The American people deserve at least 
that much. After so many years of failure, the middle class deserves 
the chance for something better. Remember, there are nearly 4 million 
Americans who have been unemployed for 6 months or longer. These 
Americans deserve to have a Congress that is committed to making it 
easier, not harder, to create jobs.
  Let's have this debate. Let's vote on Republican jobs amendments, and 
let's give some hope again to the middle-class families who have 
suffered for entirely too long.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Mr. President, I would like to respond to the Senator from 
Kentucky by again making it clear that it is my interest to work very 
closely with colleagues on the other side of the aisle on these health 
care issues, and that is why we took the proposal Senator Hatch had for 
repeal and replace on Medicare as the base bill. It is why I spent a 
lot of time working with colleagues on the other side of the aisle on 
Medicare Part D and trying to make sure it could be implemented well.
  What was striking was that a lot of the stories about Medicare Part D 
in the first couple of months resembled the stories we are now seeing 
about the Affordable Care Act. The Congressional Budget Office has made 
the comment that Part D has come in more than 25 percent less in terms 
of projected costs than what CBO saw years ago.
  We are going to work in a constructive way. I hope we will not see a 
push, for example, to repeal the Affordable Care Act because if you do 
that, you will go back to the days when health care in America was for 
the healthy and the wealthy because you would again allow 
discrimination against those with a preexisting condition. The 
Affordable Care Act has air-tight protection for those who have a 
preexisting condition, and if you repeal the Affordable Care Act, you 
would simply go back to those days.
  Working with colleagues in a bipartisan way on strengthening the 
health care system and our economy--absolutely. But turning back the 
clock on vital consumer protections, such as protecting our people from 
discrimination against preexisting conditions, is something that I 
think would be a huge mistake.
  Mr. President, I ask unanimous consent to have printed in the Record 
an article that appeared in the Wall Street Journal last weekend. It is 
entitled ``Health Insurers Make Late Push to Enroll Young People'' with 
respect to the Affordable Care Act. The signups topped the 
Congressional Budget Office's target ahead of the March 31 deadline.
  I was particularly pleased by the comments from insurance executives 
in Pennsylvania, Rhode Island, and Florida. They all talked about how 
more younger people are signing up, which, of course, is key to what we 
all want to do in terms of bipartisan approaches that strengthen the 
role of private health care in America.
  I would like to have this article printed in the Record so my 
colleagues can read the remarks of Highmark, Inc., a major health plan 
based in Pittsburgh. Blue Cross & Blue Shield of Rhode Island said 
their fastest rising segment in March was people ages 22 to 40. Florida 
Blue senior vice president Jon Urbanek said, ``Younger people are 
signing up.''
  I think all of this indicates--as far as private sector health care 
is concerned, which we all sought to promote in connection with this--
that more younger people are signing up for these plans.
  Also, in response to my friend from Kentucky who asked about the jobs 
agenda, Senator Hatch and I have been working very constructively 
together on efforts to go forward in the Finance Committee--which could 
even begin this week--to deal with the tax extenders. Tax extenders are 
particularly important for the jobs Senator McConnell seeks--as he 
mentioned in his remarks--to get some traction. We will be talking 
about an extension for the research and development tax credit, which 
is key for innovation. We will be talking about jobs and renewable 
energy and jobs for veterans. This is the kind of jobs agenda we are 
pursuing in the Finance Committee.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                     [From the Wall Street Journal]

         Health Insurers Make Late Push To Enroll Young People

             (By Anna Wilde Mathews and Christopher Weaver)

       Insurers are pressing ahead with a final marketing push to 
     bring as many young, healthy customers as possible onto their 
     rolls and buttress a recent surge in health-law enrollments.
       The flood of late sign-ups that helped boost the 
     marketplace total to six million enrollees, a key milestone 
     for the Obama administration, has also brought some insurers 
     an uptick among younger people. But it isn't clear if the 
     trend is broad enough to balance out an earlier skew toward 
     older enrollees, who are more likely to have costly ailments.
       ``We are seeing our average age come down every week, so 
     it's clear that younger people are starting to come into the 
     pool,'' said Wayne DeVeydt, the chief financial officer of 
     WellPoint Inc. ``What isn't clear yet, though, is, did it 
     come down enough.'' WellPoint has said the demographics of 
     its sign-ups have generally matched its projections.
       Highmark Inc., a major health plan based in Pittsburgh, 
     said in recent weeks that it had seen a ``marked increased'' 
     in enrollees younger than 34. Blue Cross & Blue Shield of 
     Rhode Island said its fastest-rising segment in March has 
     been people ages 22 to 40.
       Florida Blue Senior Vice President Jon Urbanek said 
     ``younger people are signing up,'' but the insurer doesn't 
     know if that will move the dial in a customer pool that had 
     been ``skewing older than we anticipated.''
       Medical Mutual of Ohio said its enrollment through the 
     health-care marketplace has gotten younger each week, and the 
     average age is now a decade below where it was when 
     enrollment kicked off in October. But, the company said, the 
     average is still eight years older than the company projected 
     when it set prices for 2014.
       Insurance officials also caution that age doesn't always 
     indicate health status-younger people may have serious, 
     expensive conditions, while some older people rarely need 
     medical services. Age is a ``pretty good predictor,'' said 
     Tom Snook, an actuary with Milliman Inc. who works with 
     insurers offering plans on public exchanges, but ``it's not 
     even close to a perfect measure.''
       So far, insurance carriers have limited insight into the 
     health needs of their new enrollees. Under the law, insurers 
     can't deny coverage or charge higher prices based on health 
     status, and enrollees need to provide only limited 
     information, including age, when they sign up through the 
     marketplaces. Enrollees must start the process of choosing a 
     plan by March 31 to avoid penalties. The Obama administration 
     has extended a grace period to complete enrollment even after 
     the deadline.
       As the deadline looms, it isn't clear just how broad the 
     uptick in youth sign-ups has been. HealthMarkets Inc., a 
     health-insurance agency, said its age balance for enrollees 
     hasn't changed in recent weeks. EHealth Inc., which tracks 
     the average age of individual purchasers of nonmarketplace 
     plans through its site, shows it flat in recent weeks. 
     GoHealth LLC, another major health-insurance site, said it 
     had seen an increase in young customers.
       To prod a big final wave, insurers, exchanges, health-care 
     providers and others are amping up their enrollment push with 
     a blitz of countdown ads and events. Blue Shield of 
     California is sponsoring events across the state, including 
     sign-ups this weekend at all 42 stores of a Southern 
     California grocery chain with many Hispanic customers. Land 
     of Lincoln Mutual Health Insurance Co. in Illinois parked a 
     tractor-trailer emblazoned with its orange logo outside a 
     hospital sign-up event on Friday.
       Health plans are particularly hoping to reach ``young 
     invincibles'' like Trevor Dawes, a 23-year-old apprentice 
     plumber from the Queens borough of New York City who said he 
     is planning to shop for a plan through New York's insurance 
     marketplace this weekend, ahead of the deadline. He learned 
     recently from a video on Facebook that he could face 
     penalties for going without insurance, which he hasn't had 
     for about a year. ``I'm healthy, and I didn't even know it 
     was important,'' he said.
       Arches Health Plan in Utah plans to keep up its push past 
     March 31 to capture late finishers. ``We're going right up to 
     the bell,'' said Shaun Greene, the company's chief operating 
     officer.
       Independence Blue Cross, which sponsored a contest to 
     create short digital films about health insurance, is turning 
     the lobby of its downtown Philadelphia headquarters into an 
     enrollment site this weekend and Monday. The insurer said the 
     average age of its enrollees has dropped by 1.5 years since 
     January.
       Arches will sport sign-up tables at three Utah Jazz 
     basketball games in the first

[[Page S1852]]

     weeks of April. Mr. Greene has enlisted his 17-year-old son 
     and some of his son's football teammates to blanket cars in 
     Wal-Mart parking lots Friday with fliers bearing slogans such 
     as ``Peace of Mind Is Priceless.''

  With that, I yield the floor.
  The PRESIDING OFFICER. The Democratic time has expired.
  Mr. DURBIN. Mr. President, I ask unanimous consent to speak for 5 
minutes as in morning business.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                         Tribute to Alan Bruce

  Mr. DURBIN. Mr. President, I wish to take a moment to thank a 
longtime member of my staff who is leaving the Senate after 27 years of 
service to Congress. Alan Bruce is not technically from Illinois, but 
he is from Indiana--in this case, close enough. The fact is that he 
served the people of Illinois in an extraordinary way during his time 
on Capitol Hill.
  For the last 22 years Alan has been my systems administrator. He 
joined my staff in 1992 when I was a Member of the House and moved with 
me to the Senate in 1997. He is the person most responsible for keeping 
my offices in Illinois and Washington connected electronically to each 
other and to the world outside the Senate. He oversees our network of 
desktop and laptop computers, BlackBerrys, cell phones, and all the 
rest.
  Over the years, he taught me a lot of things, and there was a lot to 
learn, everything from how to make my computer work, dealing with 
email, saving a digital photo, and how to Skype. He has been a good 
teacher and a hard-working, loyal member of my staff.
  In an age when most people change employers and even careers 
repeatedly, Alan is unusual. The U.S. Congress is the only employer he 
has had since he graduated from Cumberlands College--now the University 
of the Cumberlands--in Williamsburg, KY, in 1986. He didn't plan to 
come to work on Capitol Hill. Six weeks after he graduated from 
college, he was getting ready for an interview to become a manager of a 
Radio Shack in Fort Wayne, IN.
  On the morning of the interview, his mom said: You don't really want 
to do this, do you?
  Alan said: No, I really don't. My heart is not in it.
  Well, that day happened to be Saturday. It was also the day of the 
annual Circus City Days parade in Alan's hometown of Peru, IN. Alan 
canceled his interview at Radio Shack, and he and his mom instead went 
to the parade. Working the parade line that day was a new candidate for 
the House of Representatives--a man who would later become a friend of 
mine when we served together. His name was Jim Jontz. Jim introduced 
himself to Alan and Alan's mother and learned that Alan just graduated 
from college and, in fact, was looking for a job. Radio Shack's loss 
was Congressman Jontz's gain--and my gain as well. A few days after 
that parade Alan was working as a volunteer driver for Jim's campaign.
  When Jim won his election, he hired Alan to work in his Kokomo, IN, 
office helping constituents on matters related to military and veterans 
affairs. It was a good fit. Alan grew up in a military family. His dad, 
Phillip ``Bud'' Bruce, was a career Air Force man. In 1989 Alan moved 
to Washington to work in Congressman Jontz's DC office as system 
administrator. Managing a congressional computer network in those days 
was a lot different. The Internet was still an obscure tool used mostly 
by elite researchers. People didn't have email. Back then, high-tech 
communications meant fax machines. Computers were used mainly for 
keeping lists--data entry. Cell phones were a perk of just the wealthy 
few. Almost no one had ever heard of Web sites, and smart phones, 
YouTube, Twitter, and Flickr--nobody even imagined what that meant.
  Alan joined my staff as systems administrator in 1992. To give a 
sense of how dramatically his world changed, consider this: In 1997, my 
first year in the Senate, I received 30,000 pieces of mail--that is 
real mail--through the U.S. Postal Service. Last year my office 
received 600,000 pieces of mail, and only about 2 to 3 percent went 
through the post office; the rest were emails. However constituents 
reach out--whether by the postal service or email--Alan works with the 
rest of my staff to make sure their letters are answered.
  The technological revolution is only one of the big societal changes 
Alan has taken part in in the last 25 years on Capitol Hill. Alan was 
an early leader in Congress among staff to end workplace discrimination 
against lesbian and gay congressional staffers. In the early- to mid-
1990s, he was an early board member of what was then called Lesbian and 
Gay Congressional Staffers Association. The association held frequent 
brown-bag lunches to brief other staffers on issues of importance to 
lesbian and gay Americans, including the don't ask, don't tell policy 
and the Federal Defense of Marriage Act. Today, both don't ask, don't 
tell and DOMA are history. Federal employees who are legally married to 
same-sex spouses receive the same Federal privileges and 
responsibilities as other married Federal workers.
  As Alan prepares to start the next phase of his life in sunny Tampa, 
FL, I want to thank him again both for keeping my office connected to 
the larger world and, of course, to the State of Illinois and for 
keeping the U.S. Congress as an employer, moving toward the American 
ideal of equality and justice for all.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Missouri.
  Mr. BLUNT. Mr. President, according to the National Institute of 
Mental Health, approximately one in four adults suffers from a 
diagnosable mental health disorder that could be treated if diagnosed 
and treated properly. The bill the chairman brings to the floor today--
the bill that establishes the so-called doc fix, the repair and 
reimbursement issue--has an important provision in it that allows us to 
look at those individuals who have these mental health behavioral 
illnesses and begin to treat them, in eight pilot States, like any 
other illness.
  When Senator Stabenow and I introduced the Excellence in Mental 
Health Act in February 2013, our goal was to be sure that federally 
qualified centers, such as behavioral and mental health clinics, which 
met the proper standards could offer mental health treatment like any 
other kind of health treatment.
  This bill, which we will vote on later today, includes a provision 
which allows the country to have a 2-year pilot in eight States. Those 
eight States aren't designated in the legislation. The States 
themselves would step forward and say if they want to be a part of 
this.
  Certainly when we introduced this legislation in February 2013--
supported from the very start by Chairman Wyden, who has just become 
chairman of this critically important Finance Committee--we did it 
looking at the reality that people's lives have changed and the people 
they impact have changed.
  One of the things that moved the Senate toward talking about mental 
health was some of the violent tragedies we have had in the country in 
recent years. In fact, after the Sandy Hook tragedy in December--a year 
ago--the committee that deals with these issues had a hearing on mental 
health in January 2013. It was the first hearing on mental health since 
2007. For whatever reason, these are issues that, as a society, we have 
not wanted to deal with in a way we could.
  As I mention these violent tragedies, I want to be sure to say that 
people who have a behavioral illness are much more likely to be the 
victim of the crime than the perpetrator of the crime. Even when saying 
that, we know that the one consistent issue in these tragedies over and 
over in this country and other countries is that somebody has a 
behavioral illness that has not been dealt with, somebody has a clear 
need, and no one has reached out to meet that need.
  In pursuing the Excellence in Mental Health Act and now pursuing this 
pilot project for eight States, the law enforcement community has been 
widely supportive of dealing with these challenges when we can deal 
with these challenges at locations that people want to go to create 
maximum accessibility and fully qualified locations.
  The veterans community--unbelievably responsive. The Iraq and 
Afghanistan veterans community was in Washington last week dealing with 
mental health challenges. This was their No. 1 priority. We just had a 
news conference here in the building and somebody from that group was 
once again with

[[Page S1853]]

us, as they have been since February of 2013. The community that 
supports mental health and looking for mental health solutions has been 
widely supportive of what we are trying to do.
  The House passed this legislation. It is legislation we worked on--
House Members, Senate Members, bipartisan. One of the House Members, 
Dr. Tim Murphy, a psychiatrist who understands these issues, not only 
was supportive of what we were doing but we became supportive of what 
he was doing when he was advocating for people who have a behavioral 
illness--people having mental illness who are involved in a nonviolent 
crime--that dealing with their illness rather than incarcerating the 
individual is the better approach that should be available to law 
enforcement, to judges. That is an important part of what we are doing.
  The Excellence in Mental Health Act was originally cosponsored by a 
bipartisan group of 25 Senators. It has been supported by 50 mental 
health organizations, veterans organizations, law enforcement 
organizations. It creates a place where people's needs are met. The 
demonstration project would allow community mental health centers an 
opportunity to increase the types of services they provide within and 
to their local communities by providing a similar rate under Medicaid 
that federally qualified centers receive for primary care services. 
This is something we have been talking about for a long time. It allows 
government to begin to treat these behavioral challenges exactly as we 
treat other challenges--to have a healthy body, a healthy mind, all in 
one person, all in one spirit, all treatable.
  This provision in this bill that comes before us today I think is the 
beginning of a significant change in how we look at helping people 
change their lives. It is the beginning of a significant change in 
looking at mental illness as though it is any other illness. I believe 
we are going to see a good response to this on the floor today as we 
vote. More importantly, I think we are going to see a number of States 
that are incredibly interested in being one of these eight pilot States 
that will allow that to happen. I certainly hope Missouri turns out to 
be one of those States. Clearly, our State has been a leader in so 
much, including mental health, first aid. Many of our federally 
qualified clinics have added behavioral help. Many of our community 
clinics have added a level of service that this law would anticipate we 
need to have to meet community needs. I certainly have worked closely 
with the Missouri Coalition of Community Health Centers. They just 
celebrated their 35th anniversary and they are very excited about this 
legislation.
  Senator Stabenow and I were on the floor the last day of October, the 
50th anniversary of President Kennedy signing the Community Mental 
Health Act. Many of the goals of that act have not been achieved in the 
way I believe the country 50 years ago had hoped to see them achieved. 
But this legislation today includes a significant step toward that goal 
set half a century ago--still unrealized--that allows us to do things 
as a country we wouldn't otherwise be able to do.
  Senator Stabenow has been a great partner in this legislative effort, 
a great advocate for this effort. Our bipartisan friends in the House 
have as well. I look forward to a successful vote today so we can see 
this important step move forward.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. I ask unanimous consent that Senator Cardin be yielded 5 
minutes at this time to address the SGR.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The Senator from Maryland.
  Mr. CARDIN. Mr. President, I thank Senator Wyden for his leadership 
in fixing this reimbursement structure under Medicare. I thank Senator 
Blunt and Senator Stabenow for their leadership on the mental health 
demonstration program that is in this--whatever bill we pass it will be 
in--because it is absolutely essential we address the growing problems 
in our community health networks. So I thank both of them for their 
bipartisan leadership.
  The current way we reimburse physicians under Medicare is broken. The 
SGR system has been broken since it was passed in 1997 as part of the 
Balanced Budget Act. We have had 16 temporary patches to the SGR 
system, and it has created uncertainty not just among the medical 
community as to what the reimbursement rate will be for Medicare 
patients, but it has caused uncertainty among Medicare patients as to 
whether they know their doctor will be there to treat them for their 
illnesses. If we don't fix the problem and let it go off the cliff, we 
will see a 24-percent cut in reimbursements to physicians under 
Medicare. That is not sustainable. As we know, it would affect access 
for our seniors and the disabled to their doctors. We have to fix this 
problem. It expires today, March 31. So we have to take action.
  We have two choices. One is we could take advantage of the 
opportunity to not just make sure we don't go off the cliff but to 
actually fix the problem. That is what Senator Wyden has been able to 
put together, with Senator Hatch and with our colleagues in the House--
a replacement that will actually work, that will actually reward 
physicians for taking good care of their patients by managing their 
care, by bringing down the costs of health care, by managing our 
delivery system, taking high-cost patients, treating them so their 
illnesses are treated, but also done in a more cost-effective way. That 
is what the replacement would do if we could pass a permanent fix to 
the SGR physician reimbursement structure in Medicare. We have a 
bipartisan proposal. That bipartisan proposal will reward proper 
delivery of care.
  It also takes care of the therapy caps and others of the health care 
extenders. I mention that because Senator Collins and I have been 
working for a long time to try to get a permanent replacement to the 
arbitrary cap on therapy services. That was also put in the 1997 BBA--
Balanced Budget Act. That put an arbitrary cap on therapy services, so 
the more severely a person is injured, the more severe a person's 
illness, the less services they will be able to get that they need in 
order to be able to take care of the illness or injury. That makes 
absolutely no sense at all. So we fixed it.
  Why are we debating this, with strong bipartisan support? Because 
there are two proposals out there. One is the proposal Senator Wyden 
brought forward that fixes the problem, that substitutes a rational 
system, and it is paid for. I could argue it has been paid for many 
times over. It has been paid for because we have already passed patches 
that have been paid for--$153 billion. That is more than this permanent 
fix costs. Who has paid that $153 billion? It has been clinical labs; 
it has been skilled nursing facilities; it has been community health. 
All have paid for a problem they didn't create within the Medicare 
system. This has been paid for already. It has been paid for already 
many times. It is current policy.
  No one expects us to go off the cliff. Senator Wyden, in an effort to 
try to deal with this in an upfront way--CBO is now scoring this 
proposal to be a little over $118 billion. That is a bargain 
considering just a couple of years ago it was $300 billion over a 10-
year period. I remember in 2005, I filed a fix of this bill with then-
Congressman Clay Shaw--bipartisan bill. It scored at $50 billion. This 
has been paid for many times over.
  I ask unanimous consent to speak for 2 additional minutes.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. CARDIN. I thank the Chair.
  Senator Wyden, in an effort to try to accommodate everyone here, 
said, OK, we will take the cost savings that are already in the House 
bill--I could argue that really has nothing to do with the physician 
problem, but it is one I think we could agree on so we have real cost 
savings of over $20 billion that Senator Wyden has put in this bill. He 
said, we have these scored savings under the contingency operations; 
let's use that if people feel we have to have an offset, even though we 
have already paid for it over and over again.
  So we have two options: Another temporary fix with continuing 
uncertainty, continuing this problem down the road, asking those who 
didn't cause it to pay for it, even though it has already been paid for 
before or we could really take care of it and tell our medical 
community: Let's work on other

[[Page S1854]]

issues to improve our health care system rather than coming here every 
year and asking for a temporary extension of the Medicare physician 
reimbursement structure and not allowing the SGR system to take effect. 
Those are the two options we have.
  So I come here to thank Senator Wyden for putting forward a proposal 
that would fix it, that would really do it, so we wouldn't have to come 
back again next year, so Congress could really get something done. It 
is bipartisan, bicameral. The fix has already been signed off by the 
House and the Senate. Senator Wyden has come up with a plan that allows 
us to be fiscally responsible.
  I urge my colleagues to go down the path of fixing the physician 
reimbursement structure so we can take that uncertainty out of the 
Medicare law, do what is right for our Medicare beneficiaries so they 
have the certainty of their care under Medicare, and do it in a 
fiscally responsible way.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Alabama.
  Mr. SESSIONS. Mr. President, I appreciate the work of Senator Wyden 
and others on this problem. It is a matter we need to fix.
  The Senator from Maryland said the fix is signed off by the House 
too, so I guess we are supposed to know the fix is in. We are just 
going to take care of the doctors who need their money and we are not 
going to pay for it. We are not going to do it within the budget, 
again.
  As ranking member of the Budget Committee, I feel I have a 
responsibility to report to this body the plain financial truth about 
the legislation that comes before us. The bill offered by our 
Democratic colleagues is worse than this one. I guess this is a Reid-
Boehner bill that is before us now. But the Democrats' bill would claim 
to pay for it with OCO--the Overseas Contingency Operation--which 
couldn't be anything worse than the pay-for in this bill.
  The Reid-Boehner doc fix legislation we are about to consider 
violates the spending limits we passed in December, the Ryan-Murray-
raised spending limits--by $6 billion only 3 months after those limits 
were signed into law. Think about that. Bloomberg News released an 
analysis today concluding that:

       Since December 2013, the Republican House and the 
     Democratic Senate have approved more than $40 billion worth 
     of spending ``offsets'' in the form of cuts that would take 
     place in 2023 at the earliest or timing shifts in policy to 
     bring savings into the 10-year window.

  In other words, Congress has gimmicked an additional $40 billion in 
new spending in just a few months since Ryan-Murray was passed. That is 
just what it is. The Budget Committee and Chairman Murray, our 
Democratic chairman, has already ruled it violates the budget. It 
spends money we don't have. It is not a legitimate pay-for. So here we 
are again, proposing to bust the spending limits. This is the behavior 
of a profligate Congress.
  How many of our Members were running for office 2 years ago, 4 years 
ago, 6 years ago, and they were talking to their constituents and they 
said that Congress is spending us into bankruptcy; they are 
irresponsible; they won't even write a budget; they spend, spend, 
spend; they don't worry about the deficit. The country is going into 
too much debt.
  How many have said that in their campaigns--when I get there, I am 
going to do something about it. And what do they do when they get here? 
Some of our Members say, Oh, we have to take care of the doctors. And 
we do need to do that. But there is waste, fraud, and abuse and savings 
throughout this $4 trillion budget of ours that we could use to reduce 
that spending legitimately to pay for what we need to do for our 
doctors.
  That is what we agreed to do when we passed the Budget Control Act. 
That is what the Budget Control Act did. The Budget Control Act in 2011 
said this. The President signed it. It passed both Houses of Congress. 
It had Democratic and Republican support. The Budget Control Act says 
over the next 10 years we are projected to increase spending by $10 
trillion; but we are going to be more frugal than that, we are only 
going to increase spending by $8 trillion. So spending would increase 
by $8 trillion.
  What happens? As soon as it begins to bite a little bit, and we are 
challenged to make some priorities and to decide, for example, how we 
are going to help our doctor friends--who do need some relief--what do 
we do? We just violate the agreement, we spend money we do not have, 
and we say somehow it is paid for. That is what brought us the Ryan-
Murray deal and now we are rewriting that agreement. Senator Murray 
agrees that this legislation currently before us violates the budget 
and is not paid for.
  So last year we borrowed--think about this--$221 billion just to pay 
the interest on our debt. We have a debt of $17 trillion. We have to 
pay interest on it, colleagues--surely we all know that--and it was 
$221 billion last year.
  Federal aid to education is $100 billion. The Federal highway bill is 
$40 billion. We spent that much on interest last year alone. But the 
worst news is, the Congressional Budget Office tells us that 10 years 
from today our interest cost will surge to $880 billion a year 
annually. That is more than $5,000 in interest payments for every 
American worker--$880 billion. Can you imagine that? That is over $400 
a month for the average worker that pays taxes in America. That is how 
much their share is going to have to be raised in taxes to pay the 
interest in 1 year.
  What do I say about that? This assumes, colleagues--this $880 billion 
in interest and the surge in our debt--this assumes that we will adhere 
to the Budget Control Act and the Ryan-Murray agreement, which this 
bill busts and violates. It is not the first time, and it will not be 
the last. They are going to come back again and again and again with 
gimmicks and violations because people in our Congress are unwilling to 
take the heat to find real offsets.
  So we should keep that in mind as we consider this or any other 
legislation that will increase the amount of money we have to borrow.
  I would like to call attention to three specific ways the proposed 
legislation violates spending and deficit limits. Each of these are 
points of order that lie against the bill confirmed by the majority on 
the Budget Committee. What I am saying is, each of these three points I 
am raising now represent points of order; in other words, the Budget 
Committee has ascertained that they violate the budget. We spend more 
than we are allowed to spend.
  So No. 1, a $17.6 billion increase in the on-budget deficit over the 
5-year period from fiscal year 2014 through 2018; and a $9.5 billion 
increase in the on-budget deficit over the 10-year period of 2014 
through 2023--$9.5 billion.
  No. 2, spending in excess of the top line total in the Ryan-Murray 
levels for fiscal year 2014. We just passed Ryan-Murray in December. 
The President signed it in January. This is going to add $6.1 billion 
more than we just agreed to spend in fiscal year 2014.
  Oh, well, that is not a problem. I say it is a problem. I say it is 
the way a nation goes broke.
  How about this? Spending in excess of the Finance Committee's 
allocation. The committees are allocated so much money. They are not 
entitled to spend above the allocated amount. So this spends $6.1 
billion in budget authority and outlays in fiscal year 2014--this year 
we are in--above the Finance Committee's allocation.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. SESSIONS. Was there a time agreement, Mr. President?
  The PRESIDING OFFICER. There is an order to go to executive session 
at 5 o'clock. Would the Senator like to ask a unanimous consent 
request?
  Mr. SESSIONS. Mr. President, I ask unanimous consent for 2 additional 
minutes, and I will wrap up.
  The PRESIDING OFFICER. Is there objection?
  Hearing none, it is so ordered.
  Mr. SESSIONS. I thank my courteous colleagues.
  Maya MacGuineas, at the Committee for a Responsible Federal Budget--a 
well-respected group--was quoted as saying, ``We are disheartened that, 
even in a 12-month `doc fix,' the legislation under consideration would 
use a budget gimmick to offset a portion of its costs. . . . 
Specifically, a portion of the bill's `savings' are achieved by simply 
shifting sequester savings set to

[[Page S1855]]

occur in 2025 into 2024, within the Congressional Budget Office's 
scoring window, but this has zero actual impact on the debt. . . . 
Congress should remove the phony savings in this bill and replace them 
with real cuts or shorten the duration of the `doc fix.' ''
  That was an objective analysis of it.
  So, Mr. President, that being the case, the pending measure, H.R. 
4302, the Protecting Access to Medicare Act, would violate the Senate 
pay-go rule and increase the deficit. Therefore, I raise a point of 
order against this measure pursuant to section 201(a) of S. Con. Res. 
21, the concurrent resolution on the budget for fiscal year 2008.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Mr. President, pursuant to section 904 of the 
Congressional Budget Act of 1974, the waiver provisions of applicable 
budget resolutions, I move to waive all applicable sections of that act 
and applicable budget resolutions for purposes of the pending bill, and 
I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Mr. President, I now ask unanimous consent to make a 
unanimous consent request.
  The PRESIDING OFFICER. Is there objection?
  Hearing none, it is so ordered.
  Mr. WYDEN. Mr. President, I ask unanimous consent that 
notwithstanding the previous order with respect to H.R. 4302, following 
disposition of the Owens nomination, when the Senate resumes 
legislative session, the Senate proceed to the consideration of 
Calendar No. 336, S. 2157; that the substitute amendment, which is at 
the desk, be agreed to; that the bill, as amended, be read a third time 
and the Senate proceed to vote on passage of the bill with no 
intervening action or debate; and that upon disposition of the bill, 
the Senate resume consideration of H.R. 4302 as provided under the 
previous order.
  The PRESIDING OFFICER. Is there objection?
  The Senator from Utah.
  Mr. HATCH. Mr. President, I have to raise some objections, so I 
object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. HATCH. Mr. President, I ask unanimous consent that the Senate 
proceed to the immediate consideration of Calendar No. 330, S. 2122, a 
bill to repeal the Medicare sustainable growth rate offset by repealing 
the ObamaCare individual mandate. I ask unanimous consent that the bill 
be read a third time and passed, the motion to reconsider be considered 
made and laid upon the table.
  The PRESIDING OFFICER. Is there objection?
  Mr. WYDEN. I object.
  The PRESIDING OFFICER. Objection is heard.
  Ms. STABENOW. Thank you, Mr. President. I am thrilled to be here 
today as the Senate gets ready to send a proposal that I have been 
working on for several years now to the President for signature. The 
proposal, which is based on my bill, the Excellence in Mental Health 
Act, will improve quality, expand access, and ensure greater 
coordination in the delivery of mental health services through 
community mental health providers, creating an important leap forward 
in ensuring mental health parity.
  Specifically, this proposal establishes an eight-State demonstration 
program where the appropriate State agencies in the States that 
participate will certify that community mental health providers meet 
new high standards and offer a broad range of mental health services 
like 24-hour crisis psychiatric services. These services can then be 
adequately reimbursed under Medicaid just as Federally Qualified 
Community Health Centers are reimbursed for comprehensive primary care 
services.
  Now, I was incredibly fortunate to work closely with several of my 
colleagues from both sides of the aisle on this bill. But no one played 
a more important role than my friend from Missouri, Senator Blunt. 
Whether it was fighting on behalf of his constituents struggling with 
mental illness or working with our Republican colleagues in both the 
Senate and House to garner support, he was there every step of the way.
  I would like to yield to my colleague from Missouri for a question. 
Specifically, I would like to hear what role he believes the community, 
meaning community behavioral health clinics, advocacy groups, and 
families with loved ones struggling with mental illness, will--and 
should play--in the development of this demonstration project.
  Mr. BLUNT. I thank the Senator for her work on behalf of her 
constituents in Michigan and all people struggling with mental illness. 
She is a strong advocate and I am very pleased we were able to work 
together on this important issue. As she mentioned, this demonstration 
program will allow communities to improve the amount and quality of 
mental health services available to those suffering from mental 
illness.
  As Senator Stabenow and I have constructed this program, it is our 
strong and clear intent to ensure this demonstration project is driven 
by the community. Our local community mental centers are the best 
source for learning what the needs are in communities across our States 
and the country. It is critical States work not only with these 
centers, but with groups that advocate on behalf of those struggling 
with mental illness, and the patients themselves--and their families--
who can explain the difference that access to quality mental health 
services makes in the lives of people struggling with mental disease.
  For example, in Missouri, many current community mental health 
centers have partnered with community health centers in their area. 
This has worked well for Missouri providers and allows patients an 
excellent opportunity to receive coordinated care. If these pilot 
projects prove successful, which I believe they will, it is my hope we 
would see these programs continue and expand to other States, so other 
patients can benefit from higher quality services in their communities.
  I would like to yield back to Senator Stabenow to ask her to talk 
about the role she envisions States should play in the application 
process.
  Ms. STABENOW. I thank Senator Blunt for his thoughtful response and 
for his question. I could not agree with him more. From the earliest 
iterations of our bill and through our conversion to a demonstration 
project, we have fought to make sure that this is a ground-up approach 
where the local communities, advocates, and patients work with the 
appropriate State agencies to explain what the needs are and where the 
needs are, and then to have these groups come together to construct a 
State-specific approach to providing for those needs.
  What our demonstration project does not intend to do is to create a 
top-down approach where States draft proposals without comprehensive 
input from local communities to create a partnership with community 
mental health clinics, federally qualified health clinics, and VA 
outpatient centers, nor does our approach intend to permit State 
legislatures to put obstacles in the way of communities receiving the 
care and services they know they need. That type of approach simply 
adds more bureaucracy between patients and the care they need. If we 
are to achieve the true aim of our demonstration project, it is simply 
critical that communities be intimately involved in the planning and 
application process.
  Which leads me to my final question for my friend. Our proposal lays 
out a demonstration project that happens in phases. First, no later 
than September 1, 2015, Health and Human Services must publish criteria 
for a clinic to be certified as a community behavior health center and 
it must issue regulations describing how the program will work for 
States selected to participate. Then, no later than January 1, 2016, 
planning grants will be issued to States interested in exploring 
participation in the demonstration project. States are selected for 
participation in the program no later than September 1, 2017. Finally, 
the recommendations are due to Congress no later than December 31, 
2021. The theme here is ``no later than.''
  I ask the Senator, should we encourage--even expect--the 
administration to move more swiftly than the timeframe allotted?
  Mr. BLUNT. I thank the Senator for this important question. And I can 
answer it quickly. Yes.

[[Page S1856]]

  After hearing from countless people in our home States, we know that 
the time to act is now. We have a model that works and this 
demonstration project allows States the opportunity to try it in their 
communities. The dates and timeframes you mentioned for getting this 
program started should be viewed as absolute deadlines. I would like to 
see things move even quicker, if possible. We firmly believe--and 
expect--that the administration will work quickly to get this program 
off the ground. There are people around the country who will benefit 
from these services. The sooner we enact these pilot programs, the 
sooner we can test the effectiveness of this model. As I mentioned, I 
believe this model will work and am eager to see it put into place not 
only in eight States, but all 50.
  Ms. STABENOW. I completely agree. People are suffering now. Families 
are suffering now. While we understand that the administration needs 
time to implement this demonstration project in a sound and effective 
way, we are in absolute agreement that the expectation is that the 
administration will work expeditiously to ensure that actions are taken 
well in advance of deadlines.
  I thank the Senator for his tireless work on behalf of Missourians 
and all Americans suffering with mental illness. I thank him for 
fighting beside me to get us here today. I know we would not have 
crossed the finish line without his efforts and for that I am grateful.
  Ms. COLLINS. Mr. President, the tragic shootings at Sandy Hook 
Elementary, the Aurora movie theater, and the Washington Navy Yard 
served as wake-up calls to our Nation that action must be taken to 
provide better care and support for Americans living with mental 
illness and their families.
  As an original cosponsor of the bipartisan Excellence in Mental 
Health Act, I am pleased that the bill before us today includes a 
provision, based on our legislation, to establish pilot programs in 
eight States to strengthen and improve access to quality community 
mental health services.
  Unfortunately, patients with serious mental conditions all too often 
lack access to care and experience difficulties obtaining appropriate 
and sustained treatment for their illness. Over the course of a year, 
fewer than half of those with severe mental disorders receive any 
treatment at all. Treatment rates are even worse for children, 
adolescents and young people between the ages of 16 and 24. This is 
especially troubling given that nearly half of all lifetime cases of 
psychiatric conditions begin by the age of 14, and 75 percent by the 
age of 24.
  Of the 20 percent of Americans who will suffer from mental illness at 
some point in their lives, just one in five will receive professional 
care. These kinds of numbers would be totally unacceptable for patients 
afflicted with cancer, diabetes, heart disease or any other physical 
disorder. They therefore should not be accepted for schizophrenia, 
bipolar disorder, severe depression, or any other serious mental 
illness.
  I am particularly concerned about the high rates of suicide among our 
active duty military and returning veterans. The number of reported 
suicide deaths in the U.S. military surged to a record 349 in 2012, 
which is more than the number of servicemembers who lost their lives in 
combat in Afghanistan during the same period of time.
  The number of suicides among veterans has reached an astounding rate 
of 22 a day according to some studies. These losses are simply 
unacceptable. With at least 25 percent of returning veterans from Iraq 
and Afghanistan experiencing some type of mental health condition, it 
is even more urgent that comprehensive mental health services be 
available in communities across the country. This is particularly true 
in rural states like Maine, where mental health services may not be 
easily accessible through the VA.
  We know that people suffering from mental illness are more likely to 
be the victims of violence than the perpetrators. However, we also have 
seen too many tragic examples of what happens when people with serious 
mental illness do not get the treatment and services they need.
  The legislation that we are considering today has been endorsed by 
more than 50 mental health organizations, veterans organizations and 
law enforcement organizations. It takes an important first step toward 
expanding access to care and improving quality of care so that more 
people living with mental illness can get the treatment they need in 
their communities.
  In closing, I want to commend my colleagues from Michigan and 
Missouri for their tireless work to increase access to community mental 
health services and to improve the quality of care for those living 
with mental illness.
  Mrs. SHAHEEN. Mr. President, I am disappointed that we were unable to 
come together to permanently repeal the Sustainable Growth Rate 
formula, and instead passed a 1-year patch to prevent reimbursement 
cuts for physicians from going into effect in April.
  The bill the Senate passed tonight averts a 24 percent cut to 
Medicare payments that would start tomorrow, April 1. Given the 
potential impact of such a large cut to Medicare patients and to their 
physicians, I supported this measure.
  While a patch is not the permanent solution many of us have sought, I 
voted for it because we must act to prevent these cuts from taking 
place. Having averted these cuts, I will continue to work for a 
bipartisan solution to permanently repeal the SGR.
  I look forward to working with my colleagues to achieve this goal.

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