In signing the historic health care reform legislation yesterday, President Obama ushered in a new era that will make great strides to address serious problems with our current health care system. These improvements cover an estimated 32 million uninsured Americans, move toward a system of prevention, and use information technology and incentives to modernize and improve health quality.

For children, health reform came on the heels of the passage of the Children’s Health Insurance Program Reauthorization Act (CHIPRA). Children’s advocates supported the President’s promise to “build upon what works” and let people keep the coverage they have. CHIPRA provided enough funding to dramatically cut the uninsured rate for children in half by 2013, which currently stands at just over 8 million. As a result, health care reform truly begins with children, as the most significant progress that will be made on health coverage over the next few years will actually be due to the renewal and expansion of the Children’s Health Insurance Program (CHIP).

As Jocelyn Guyer at the Georgetown Center for Children and Families has said, "Many of the improvements included in CHIPRA will lay the foundation for a successful transition to an era where everyone has access to affordable, reliable health coverage. The better job states do right now in removing red-tape from the system and reaching out to eligible but unenrolled children, the stronger the foundation will be for them to seize the opportunity to transform our health care system into one that works better for everyone."

To get to this point, children had to survive some initial scares, such as two vetoes of CHIP by President Bush that was followed this year by the House of Representative’s original plan to repeal CHIP and move millions of children into the untested “health insurance exchanges.” Thankfully, the final health reform legislation includes a myriad of critically important provisions for our nation’s young people. For example, the bill:

· Protects and expands CHIP, which has successfully worked with Medicaid to drive down the number of uninsured children to its lowest level in over 20 years, through 2015.

· Provides additional federal fiscal support to state Medicaid and CHIP programs, ensuring that access to coverage is not threatened.

· Addresses enrollment and bureaucratic barriers that would substantially streamline eligibility and improve coverage for low-income children and families.

· Ensures that no child can be denied by insurance companies for coverage based on pre-existing conditions, such as childhood diabetes, sipina bifida, etc.

· Makes coverage more affordable for middle class families by boosting their bargaining power through new health insurance exchanges and providing tax credits to help subsidize such family coverage.

· Allows parents to keep their college-age children up to age 26 on their family health plans.

· Requires that insurance companies provide coverage that meets the unique health care needs of children.

However, the Senate was unable to take action on amendments filed by Senators John D. Rockefeller, IV (D-WV) and Robert Casey, Jr. (D-PA) that would have made permanent and fully funded CHIP well into the future, guaranteeing coverage for all our nation’s children. Instead of a large-scale victory for children’s coverage, the legislation leaves CHIP set to expire at the end of 2015.

This oversight is largely due to the outlandish system that is now in place, in which any action in Congress hinges almost entirely upon the delivery of a “score” from the Congressional Budget Office (CBO). These scores are often inaccurate, withheld, or not completed in a timely manner. In the case of health reform, CBO assumed an all-powerful role over the coverage and well-being of millions of people, as the fate of any health reform proposal rises and falls on the CBO scoring process.

In the case of the Rockefeller and Casey amendments, language was submitted over five months ago and was never scored, despite numerous promises otherwise. Moreover, even at this date, Members of Congress never have received any information on the expected coverage levels or costs for children in any of the various programs. Therefore, in addition to looking to guaranteeing coverage for all children, Congress should undertake a serious review and overhaul of the CBO scoring process. Their work has taken on a level of importance to millions of people across country that necessitates better quality, timeliness, and transparency.

Beyond CBO, what has been most striking about this process is that, despite the inflammatory rhetoric otherwise, the new health reform law is actually quite moderate. It is far from the sweeping changes that both sides of the aisle are claiming. For example, it neither provides coverage to all Americans, as some have declared, but neither is it the “coming of the apocalypse,” as others have affirmed.

Having worked for Senator Bob Graham (D-FL) during the last attempt to achieve national health reform in 1993, the legislation actually looks strikingly similar to the proposal assembled by the late Sen. John Chafee (R-RI) and a number of other Republican moderates, such as Dave Durenberger (R-MN) and John Danforth (R-MO). Both bills offer coverage though Medicaid for those in poverty and provide subsidies or tax credits for other low-income populations to purchase private health insurance. Both bills require insurers to offer some sort of standard benefits package and to refrain from discriminating based upon “pre-existing conditions.” These efforts actually build upon the current private health care system and are far from the sweeping and apocalyptic tone that is currently swirling around the debate.

Once the cries for “repeal” by opponents’ such as Newt Gingrich subsides, there is no way that politicians will actually pursue throwing 32 million of people off of coverage, affirmatively imposing pre-existing condition exclusions upon people with chronic medical conditions, etc. My hope is that instead, our nation will honestly engage in an effort to finish the job of truly covering all Americans and controlling costs, as is highlighted in posts by Dave Kendell and John Shiels.

With our nation’s economy and the health and well-being of the country at stake, these are problems that cannot remain unresolved.

Sunday night’s historic vote by the House is the critical first step toward truly transforming our nation’s health care. By setting into motion long-overdue efforts to cover 32 million uninsured Americans, we can now move forward to address the many complex issues that have beleaguered us for decades. In other words, our long day’s journey into health care reform is far from over. Numerous challenges—as well as opportunities—await.

For example, will there be a doctor in the house to accommodate millions of newly covered Americans, as well as a rapidly growing Medicare population? U.S. medical schools have been working diligently to expand the physician workforce through increased medical school enrollment. Congress must now join the effort by lifting caps on Medicare-supported residency positions so that future physicians can finish their training.

At the same time, Congress also must establish a physician payment system that truly reflects the costs of caring for Medicare beneficiaries, both now and in the future. The recent short-term freeze on Medicare physician payment cuts, while helpful, was only a temporary patch to the current, but deeply flawed, physician payment formula.

Another challenge is bending the cost curve in a way that doesn’t undermine or sacrifice the nation’s safety net. Toward this end, the nation’s teaching hospitals—which provide 71 percent of all hospital-based charity care (and are a source of innovation for redesigning patient care)—must remain fiscally viable. Proposed cuts to Medicare and Medicaid disproportionate share hospital payments—which would significantly reduce funding for these institutions before the outcome of coverage expansion is known—must be carefully monitored. Similarly, by establishing an Independent Payment Advisory Board, special care must be taken to avoid unintended and negative consequences, such as jeopardizing patient access to health care services provided by teaching hospitals and clinical providers.

Yet even as we work to address these challenges, we must be mindful of the once-in-a-lifetime opportunity before us: the chance to finally align fundamental changes to the delivery system with changes in financing. The AAMC and its members continue to advocate for healthcare innovation zones, a critical venue for testing and exploring related business models and innovations.

Just as we have a moral imperative to provide Americans basic health insurance, we have an innovation imperative to finally make our health care system work for everyone. All of us must be prepared for the hard work ahead. The nation’s medical schools and teaching hospitals stand ready to work with the administration and Congress toward the health care system we all visualize and deeply desire.

The historic action by the House of Representatives in passing comprehensive health reform legislation will usher in a new era in American health care—one in which all Americans will be able get the care they need without incurring financial hardship, and no American will be denied health insurance coverage simply because they have a preexisting medical condition.

Many Americans will feel the effect of reform this year, as significant changes start to go into effect. Within the year:

• underwriting of children in the individual market will be prohibited;
• young adults will be able to stay on their parents' health plans to age 26;
• insurance companies will be prohibited from revoking coverage when people become ill, and from setting lifetime limits on benefits;
• small businesses will be eligible for new tax credits to offset their premium costs;
• people with preexisting conditions will be eligible for subsidized coverage through a national high-risk pool;
• new limits will be set for the percent of premiums that insurers can spend on non-medical costs and, beginning in 2011, carriers that exceed those limits will be required to offer rebates to enrollees;
• Medicare will provide $250 rebates beneficiaries who reach the donut hole; and
• Medicare will eliminate cost-sharing for preventive services in Medicare and private plans.

All of these improvements in health benefits for Americans will occur in a way that does not add to the federal budget deficit or accelerate the growth in health care spending.

The Congressional Budget Office estimates that health reform, as passed by the House of Representatives, will reduce the federal deficit by $143 billion over the next 10 years (2010–19). Congress is making the tough choices to both achieve savings of about $500 billion in the current federal budget over the next decade, and raise the revenues needed to finance the balance of the federal budget cost of this important reform.

Commonwealth Fund estimates indicate that total health spending will slow under this reform—from a 6.6 percent annual rate of increase to less than 6 percent. Employers and workers will also realize savings. Health insurance premiums will be reviewed—preventing increases of 20 to 40 percent that have recently been proposed by insurance companies. Reform will save the average American family $2,500 in 2019.

Most important, the legislation will put the U.S. health system on a path to high performance, allowing us to join all other major industrialized countries with a system for ensuring access to essential health care, improved quality, and greater efficiency. It is a victory for all Americans, who deserve the finest health system in the world.

First, there was a fight over enactment. Next, there will be a fight over repeal. But after the dust settles, health care reform will be the foundation for providing stable coverage to America's middle-class. It will also launch a quiet, but far-reaching transformation of how our nation pays for health care.

Experts of all political stripes have called for reforming the current “fee-for-service” system, where doctors are paid for individual procedures they perform but not for the overall result.

The current system, for example, lets doctors who cause infections through improper hand-washing send more bills to treat it. In effect, doctors are paid more if they make mistakes and fix them than if get it right the first time. Tens of thousands of medical errors are committed every year, ranging from gross errors such as the amputation of the wrong leg to accidental errors in dosing medication.

Health reform will require hospitals to effectively put a warranty on their care by limiting the payments they get from Medicare if a patient is readmitted to the hospital for what is considered a preventable reason. The result will be fewer medical errors, including fewer preventable readmissions and fewer patient injuries and deaths—and a reduction in the $17 billion and $29 billion per year that hospitals now spend to fix medical errors.

Another major aspect of cost control in health reform is the limit it will place on tax subsidies for excessively generous benefit packages. Under current law, employee health benefits are paid for with pre- tax dollars—a subsidy that amounts to 35 to 40% of the total cost of premiums. In 2008, taxpayers spent $226 billion to subsidize employer-provided insurance.

While employers should continued to be rewarded for providing benefits to their workers, the current system does not differentiate between efficient and inefficient health care plans, and there’s no reason why taxpayers should subsidize an over-the-top package for an executive with a multi-million dollar salary.

The health reform bill would limit this subsidy by levying a 40% excise tax starting in 2018 on the annual premium amount over $27,500 for family coverage and $10,200 for individual coverage with adjustments for inflation, age, and other factors. Most of the revenue generated by the provision would not come from the tax itself. Instead, it would come from employers eliminating bloated benefits, which in turn would mean higher wages that are subject to taxation. Thus, this provision will not only reduce health care costs, it will increase worker wages.

Third, the health bill will ensure more head-to-head competition among insurers.Most workers today can’t choose among competing health plans based on price and quality, which means less pressure to hold down costs. Because employers pay for most of the health care coverage in the United States, the vast majority of private-sector employees don’t have the chance to save money for themselves by choosing more economical health plans. Reform will create an electronic marketplace, or “exchange,” where plans will compete for business. This will mean more choices for consumers and more competition among plans to keep prices lower while providing better benefits.

A successful example of an insurance exchange is in Madison, Wisconsin, where the market is dominated by state employees who can make their own choices about their coverage and the cost they pay. Health insurance in the Madison area costs 14% less than the statewide average.

Health care reform takes on an entrenched and inefficient system with bad habits that have accumulated over decades. It will bring a new level of accountability to the health care system that it lacks today.

Health reform passed last night with a vote in the House of Representatives of 219-212. I'll have a lot to say about what's in the bill and what the reconciliation package going to the Senate does to make it better, but for now, some perspective is in order.

Two quotes by Dr. Martin Luther King Jr. sum up this rapidly closing episode of American history. First, Dr. King succinctly illustrates why health reform was and still is a moral imperative:

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."

Health care is an issue taken up by advocates of the public interest everywhere because of this simple and powerful fact. Injustice in health care is an injustice that flies directly in the face of the ideals this country was founded on. As Speaker Pelosi remarked last night, Life, Liberty and the Pursuit of Happiness is what pushes us all to work for health reform. Making America live up to its ideals is what reform is all about.

A second quote by Dr. King sums up for me what the vote last night did to fix this inequality:

"The arc of the moral universe is long, but it bends toward justice."

The health care bill passed last night bends that moral arc towards justice in this country.

There is more work to do - indeed, there may always be more work to do - to rub out the inequality that exists in health care in America. But there is no question today that America has made determined progress towards a more just society, and a more perfect Union.

Tomorrow, we resume the fight to pass the final health reform provisions through the Senate on an up or down vote. But today, I'm thinking about the progress we've made and the progress we have yet to accomplish.

The health reform debate has been at the center of a decades-long struggle in this country to find the balance between liberty and equality – two fundamental principles that form the genius of America.

Freedom is the fulcrum of our prosperity with respect for the right of every one of us to pursue our dreams and happiness. And the conviction that all of us are created equal guides our compassion out of respect for the dignity of every person. America is great because we value both, and both are vital to the strength of this great country.

Legislators bring those convictions to the process of developing legislation, and that is, I think, behind their cry for bipartisanship. The American people want both liberty and equality to guide careful legislative decisions that balance these principles in our unique democracy.

But last night, we saw an arrogant abuse of the process and of political power. The American people have spoken in every way they can that this bill does not produce either equality or liberty; they fear it will devolve more and more power to Washington and to the political process -- that it puts too much power in the hands of government and too little in the hands of freedom-loving people.

I had the privilege of watching the debate unfold in the House gallery last evening as a guest of Rep. Jeff Fortenberry of Nebraska and his chief of staff, Kelly Lungren McCollum, and I thank them deeply for inviting me to be there in person.

I heard many false promises: “Every uninsured American can become insured,” said Rep. Lloyd Doggett (D-TX). Speaker Pelosi said: “This legislation will lead to healthier lives, more liberty to pursue hopes and dreams and happiness for the American people. This is an American proposal that honors the traditions of our country.”

Other Democrats said that people won’t have to lose their health coverage and that they can see a doctor anytime they want. And over and over we heard that this huge new government entitlement will reduce the deficit.

But the actual bill defies those promises.

“You can’t improve the health of a nation by bankrupting its children,” Rep. Jeb Hensarling said. “This bill fundamentally changes the relationship between government and free people.”

Rep. Paul Ryan spoke about the larger vision of America. “America is not just a nationality,” he said. “America is an idea. It’s the most pro-human idea ever designed by mankind.”

But he warned “we are fast approaching a tipping point where more Americans depend on the federal government than on themselves for their livelihoods – a point where we, the American people, trade in our commitment and our concern for our individual liberties in exchange for government benefits and dependencies….

“Do we believe that the goal of government is to promote equal opportunity for all Americans to make the most of their lives – or do we now believe that government’s role is to equalize the results of people’s lives?

“The European social welfare state promoted by this legislation is not sustainable. This is not who we are and it is not who we should become.

“Today marks a major turning point in American history. Our founders got it right, when they wrote in the Declaration of Independence that our rights come from nature and nature's God – not from government,” Ryan said.

Thirty four Democrats voted with the Republicans and against ObamaCare. Not one of them was given a chance to speak last night. Most agree with Republicans in their concern about how this violates the culture of this country.

The American people are rising up and letting their legislators know every way they can that ObamaCare got it wrong. This sweeping, 2,700-page bill will be signed into law, likely this week. The debate over a second bill in the Senate is only a sideshow. The health overhaul law is passed. ObamaCare will be the law of the land.

Battles will continue in the courts, in the states, in the Congress, in the media, and around dining room tables, likely for years to come.

And the people’s voice will be heard the next time they have a chance to speak, at the polls in November. But today is a sad day for our great country. Neither the cause of equality nor liberty has been served. As Republican Leader John Boehner concluded, in voting for this bill, “We break our trust with Americans.”

To many Americans, health reform is more about preserving the status quo than it is about change. Surveys show that most of the 85 percent of Americans who have insurance like their coverage and want to keep it. Advocates have promised the bill will protect the coverage Americans now have by slowing cost growth. But cost control appears to have taken a back seat to expanding coverage for the 15 percent of Americans who do not have insurance.

Proponents of the bill often point out that many Americans will see their premiums go down under the bill. This is true, but mainly because the bill provides new subsidies for the purchase of coverage. Little of these premium reductions can be attributed to actual reductions in the cost of services or increased efficiency. And as we all know, premiums will go up for younger and healthier people who now must pay a community rated premium.

To be fair, much of the 2,700 page bill is devoted to changes that increase the emphasis on prevention and quality. David Cutler, a Harvard professor and advisor to president Obama, predicts $600 billion in savings to consumers and governments from the bill over 10 years, which is equal to about 1.5 percent of national health spending over that period. However, we have estimated that savings would be more than offset by increased spending for newly insured people for a net increase in spending of $265 billion.

The bill does begin to realign provider incentives under Medicare with demonstrations of payment systems that promote improvements in quality and efficiency such as the medical home and pay-for-performance (P4P) models. It also introduces a “bundled” payment system that provides a single payment for individual episodes of care, creating new incentives to improve quality and reduce unnecessary spending. However, the CBO shows that savings are expected to be small.

While the bill is a disappointment to cost containment “Hawks”, it may be the best that our political system is capable of right now. Americans are not ready to submit to any system that interferes with unrestrained access to health providers and services. Unfortunately, that eliminates most of the options that might make a difference. We may learn a lot from the Medicare demonstrations in the bill. But it will be up to the private sector to engineer the next generation of cost containment.

The 219 House Democrats who voted to pass ObamaCare may think their vote puts health reform behind them so they can move on to other issues.

Dream on. President Obama’s reassurances that the public’s opposition to this massive overhaul legislation will turn to approval are pure fantasy.

The American people have rejected the substance of the health overhaul legislation, they are repulsed by the special deals and pork used to get it passed, and they are outraged that Speaker Pelosi jammed the bill through with threats and promises to members despite the deafening disapproval of the American people.

Democrats issued a list of the Top Ten Immediate Benefits the bill will offer, but they are either too modest to affect many people or likely will cause unintended consequences. Everything bad that happens next in our health sector will be blamed on the inevitable failings of this top-down, centralized approach to reform.

The uninsured rolls will continue to swell, it will be harder and harder to find a doctor as many quit the practice of medicine altogether, deficits will continue to soar, and the quality of care will get steadily worse as doctors and hospitals become more responsive to bureaucrats than to patients. In addition:

1. Cost: Health insurance costs will continue to soar. Premiums will continue to rise and will likely rise faster because of new mandates on insurers that add costs to policies.

2. Medicare: The added drug benefit will assist a few, but at least 10 million seniors are threatened with losing their Medicare Advantage benefits and plans because of deep cuts to the program. When they lose their coverage, they will blame ObamaCare. And it will come sooner rather than later.

3. Jobs: Employers will face new taxes as well as fines and penalties if they don’t provide insurance or if one or more of their employees seeks coverage in the new government exchange. Hiring new workers, particularly entry-level employees, will be a risk fewer employers will be willing to take.

4. Coverage: Many people who value their job-based insurance could lose it. Employers will face huge risks if they continue to offer health insurance, and already are considering dropping health benefits altogether. Many will find it is cheaper to pay the fine and send their employees to the exchanges or other government plans than to pay for increasingly-expensive, government-defined insurance for their workforce.

Members who voted for this bill, boasting of its benefits, should expect to find themselves perpetually on defense in explaining the cascade of problems it creates. An electorate that has been so ignored in this process will look for every opportunity to remind them of the high cost of false promises.

There have been 8 versions of ObamaCare. The numbers below are estimates made for one or more of them. We believe they are still in the ballpark, and we will update as more information becomes available.

"If you like the plan you are in you can keep it."

19 million

Number of people predicted to lose their employer plan (Lewin Group)

8 to 9 million

Number of people predicted to lose their employer plan (CBO)

$11,543

Employer incentive to drop coverage for a $30,000 a year worker with family [Tax subsidy in the exchange minus tax subsidy at work minus $2,000 fine] (IRET)

8.5 million

Number of seniors and disabled people at risk of losing their Medicare Advantage plan (Medicare Chief Actuary)

3 million

Additional people who will likely lose Medicare Advantage plan benefits (Medicare Chief Actuary)

$816

Average annual benefit loss for 11 million seniors and disabled in Medicare Advantage plans (CBO)

33 million

Number of people in traditional Medicare at risk of losing access to care because of $523 billion in cuts in Medicare spending (Medicare Chief Actuary)

20%

Fraction of hospitals that would become unprofitable after Medicare spending cuts (Medicare Chief Actuary)

“There will be no tax increases for anyone who earns less than $200,000.”

73 million Number of people who earn less than $200,000 who will see their tax bill rise (Joint Committee on Taxation) 40% Tax rate on “Cadillac” plans (Reconciliation Summary) 2.3% Hidden tax on wheelchairs and other medical supplies (CBO update) $27 billion Hidden “medicine cabinet” tax on drugs (Reconciliation Summary) 10% Tax on tanning salons (Reconciliation Summary) $60 billion Hidden health insurance tax (Reconciliation Summary)

“Health insurance reform is…about creating a climate where our entrepreneurs and small businesses can succeed [and] about giving you the chance to prosper and grow.”

$100 million Cost of ObamaCare mandates for Caterpillar, Inc. in the first year alone (Caterpillar, Inc.) 60% Implicit marginal tax rate for workers earning as little as $25,000 (IRET) 65% Implicit marginal tax rate for families earning as little as $50,000 (IRET) 0.9% New payroll tax on the wages of entrepreneurs and small business owners (Reconciliation Summary) 3.8% New tax on the capital income of entrepreneurs and small business owners (Reconciliation Summary)

"The average family will save $2,500 in health care costs by the time I complete my first term as President of the United States.”

111% Premium increase for individual insurance (AHIP) 54% Premium increase for individual insurance (BlueCross BlueShield) 106% Premium increase for individual insurance (Wellpoint) $2,100 Premium increase for the average family (CBO)

"Over the past year the House and the Senate have been working on an effort to provide health insurance reform that lowers costs …”

$220 billion Rise in national health care spending over the next 10 years (Medicare Chief Actuary)

“… that guarantees access to care …”

15 million Number of new people added to Medicaid, where care is increasingly rationed and where provider choice is increasingly restricted. (CBO) 0 Number of new doctors and nurses trained and number of new hospitals built to meet the needs of 32 million newly-insured (CBO)

” … and enhances the quality of health care for all Americans.”

24 million Number of people who will enter a health insurance exchange where health plans will have an incentive to underprovide to the sick. (CBO/NCPA)

“This is not about big government …”

16,500 Additional IRS auditors needed to enforce the legislation (Ways and Means Minority Report)

“This legislation will protect families …”

$6,000 to $10,000 Marriage penalty if two $32,000-a-year workers say “I do.” (Ways and Means Minority Report)

"We are going to get rid of the special deals …”

$7,300 Extra exemption from the Cadillac premium tax for members of labor unions. (Ways and Means Minority Report)

"This bill will reduce the federal deficit …”

$562 billion Increase in the deficit after removing budget gimmicks and unrealistic tax increases and budget cuts relegated to future Congresses (CBO former director)

This will not stand. No one should be confused about the outcome of Sunday's vote.
This is not the end of the fight it is the beginning of the fight.

The American people spoke decisively against a big government, high tax, Washington knows best, pro-trial lawyer centralized bureaucratic health system.

In every recent poll the vast majority of Americans opposed this monstrosity. Speaker Pelosi knew the country was against the bill. That is why she kept her members trapped in Washington and forced a vote on Sunday. She knew if she let the members go home their constituents would convince them to vote no.

The Obama-Pelosi-Reid machine combined the radicalism of Alinsky, the corruption of Springfield and the machine power politics of Chicago.

Sunday was a pressured, bought, intimidated vote worthy of Hugo Chavez but unworthy of the United States of America.

It is hard to imagine how much pressure they brought to bear on congressman Stupak to get him to accept a cynical, phony clearly illegal and unconstitutional executive order on abortion. The ruthlessness and inhumanity of the Obama-Pelosi-Reid machine was most clearly on display in their public humiliation of Stupak.

The real principles of the machine were articulated by Democratic Congressman Alcee Hastings who was impeached and removed from the bench as a federal judge, before being elected to the House when he said, "There ain't no rules here, we're trying to accomplish something. . . .All this talk about rules. . . .When the deal goes down . . . we make 'em up as we go along."

It is hard for the American people to believe their leaders on the left are this bad.

They are. The American people will not allow a corrupt machine to dictate their future.

Together we will pledge to repeal this bill and start over. Together we will prove that this will not stand as 2010 and 2012 will be among the most important elections in American history These elections will allow us to save America from a leftwing machine of unparalleled corruption arrogance and cynicism. Sunday was one more step in the fight against a "Washington knows best" and "Washington should run everything" attitude.

Let us turn now to the Senate to continue this fight for real reform, for real self government, and for policies that create jobs, improve health outcomes, and increase freedom.

This is a historic day. We have worked to enact health reform in America for decades. President Johnson took a major step when he signed Medicare into law in 1965 and guaranteed every American age sixty-five and over quality, affordable health care. Forty-five years later, we are about to extend that guarantee to all Americans.

It isn’t the bill I would have written. However when it comes to legislating health insurance reform in America, we will not get everything each of us want. This bill is a compromise that bridges the differences among us. It will:

• extend coverage to 95% of all Americans.
• Assure affordability of health insurance by providing tax credits and cost-sharing assistance to families up to 400% of poverty.
• Halt abuses of the health insurance industry – forcing them to compete on quality, not just their ability to avoid covering needed health services.
• Guarantee a standard benefit package for all Americans with an annual cap on out-of-pocket spending. No family should go bankrupt because of medical expenses.
• Create a new marketplace, called an Exchange, where people will be able to comparison shop among health insurance plans.
• Require that insurance plans spend at least a certain percentage of their premium dollars on benefits and end discrimination by health status, gender, occupation.
• Help senior citizens by filling the Republican Medicare prescription drug donut hole – ensuring that Medicare beneficiaries will be able to afford their medications year-round.

There are components I wish had turned out differently and I pledge to continue working to improve them. In particular, I have some concerns about Medicare.

I oppose the inclusion the Independent Payment Advisory Commission, called IPAB. Some of my colleagues support this Commission because it shields them from having to take tough votes when it comes to cutting Medicare provider payments. It’s my experience that Congress always does what is needed to protect and strengthen the Medicare program. IPAB is a dangerous provision. By statute, this Commission would be required to hold Medicare spending to an arbitrary and unrealistic growth rate. It is a mindless-rate cutting machine that sets the program up for unsustainable cuts. That will endanger the health of America’s seniors and people with disabilities. It is an unprecedented abrogation of Congressional authority to an unelected, unaccountable body of so-called experts. I intend to work tirelessly to mitigate the damage that will be caused by IPAB.

I am pleased that this legislation reduces government overpayments to private health insurance plans in Medicare and that our reconciliation negotiations improved on those savings. It still should eliminate the overpayments. I support the choice of private plans in Medicare, but I don’t support wasting taxpayer dollars on corporate subsidies to achieve that goal. Plans that can meet or beat Medicare should be allowed to participate. Those that can’t should be excluded. We’ve got more work to be done here.

We also lost a provision in the House bill that ensured Medicare beneficiaries in private plans would never pay higher cost-sharing for Medicare services than if they were enrolled in traditional Medicare. I’ll be working with the Administration to see that they move forward with steps in their authority to resolve that disparity.

I am disappointed in the lack of a public health insurance option. This provision fell victim to the strength of the insurance industry lobby. It would have saved taxpayers money, enhanced competition, and increased efficiencies. That it isn’t in this bill does not mean it can’t be added in the future.

These flaws are what one must expect when bringing a bill through the US Congress that touches more than one-sixth of our economy. In the past, we’ve allowed health reform to fail because of similar imperfections. We did not let that happen, and we have passed legislation that will finally provide affordable, quality health care to all Americans.