March 31, 2014 - Issue: Vol. 160, No. 51 — Daily Edition113th Congress (2013 - 2014) - 2nd Session
PROTECTING ACCESS TO MEDICARE ACT OF 2014; Congressional Record Vol. 160, No. 51
(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 President, I ask unanimous consent that the order for the quorum call be rescinded.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 President, I ask unanimous consent that the order for the quorum call be rescinded.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. ____________________