Speeches & Floor Statements

Floor Remarks of U.S. Senator Lamar Alexander (R-Tenn.) -- Colloquy with Sen. Johnny Isakson (R-GA) on Health Care Reform

Posted on October 1, 2009

Mr. ALEXANDER. Madam President, I ask unanimous consent that the Senator from Georgia and I be permitted to engage in a colloquy. The ACTING PRESIDENT pro tempore. Without objection, it is so ordered. Mr. ALEXANDER. Madam President, I ask if the Acting President pro tempore will let me know when we have 5 minutes remaining on the Republican side. The ACTING PRESIDENT pro tempore. All right. Mr. ALEXANDER. Madam President, the Senator from Georgia and I wish to talk a little bit today about the health care plans coming through. Fundamentally, our position is that we do not want to see another Washington takeover. We are deeply concerned about the cuts in Medicare that will affect seniors, about the taxes -- both the increase in Federal taxes and State taxes, which we will talk more about -- about the trillion dollars in new spending, and about the threats to the health care choices the legislation coming through would pose. Instead of such a large enterprise as what I have just described, we would propose that we take practical, small steps to reducing costs such as allowing small businesses to pool their resources, reducing junk lawsuits against doctors, allowing consumers to purchase across State lines, and creating health insurance exchanges. There are other steps that could be taken; in other words, instead of scaring the country half to death with new taxes and Washington takeovers and threatening their health care choices, let's don't throw the whole system out. Let's take practical steps to reduce costs and to improve services. Today we wish to specifically talk more about two government-run programs that already exist. One is Medicaid, which is the program for low-income Americans that today serves about 59 million Americans. About 60 percent is paid for by the Federal Government and about 40 percent by the States. The second is Medicare, which seniors know very well because about 40 million American seniors are dependent upon Medicare. We are concerned because the proposals coming through the Senate Finance Committee would shift costs of Medicaid to the States, causing State budgets to be put in ruin, according to the Governors of those States, and either taxes go up or services are cut. We are concerned because the President and others have said we are going to pay for this big new program by savings in Medicare, not to be put in Medicare for seniors, but for the new program. A lot of people say it is hard to find opportunities for bipartisanship when we talk about health care, but I think I have found one. I am on the Senate floor today to say I would like to be a cosponsor of the Reid amendment, the proposal by the majority leader of the Senate -- the respected Harry Reid from Nevada. The New York Times reported yesterday that the majority leader had heard from his Governor and from other people in his State, and he was deeply concerned about the legislation that is coming through because it would increase costs in Nevada. In fact, I have a copy of the letter from the Governor of Nevada to majority leader Harry Reid, and it says: As you know, like the U.S. Constitution, most State constitutions require a balanced budget, including Nevada. Nevada will spend $907 million for programs on Medicaid. This is about 14 percent of our budget. We can't afford more taxes. Revenues are down. So the majority leader did exactly what I think a Senator would do. He introduced an amendment, or proposed an amendment, to the Senate Finance Committee and said: Take care of Nevada. If the Federal Government is going to expand coverage for Medicaid, then the Federal Government ought to pay for it. That is exactly what I believe. That is exactly the opinion of all of the Governors. The National Governors Association, of which I used to be chairman, has said to us: If you are going to expand Medicaid, if that is your big idea in Washington, then pay for it. Nothing irritates Governors and legislators more than Washington politicians who come up with big ideas, announce them, take credit for them, and then send the bill to the Governor and the legislature. I was a Governor. The Senator from Georgia was in the Georgia Legislature for 17 years. He was the leader of the Republicans in the senate for 8 years. He knows a good deal about State budgets and about the Medicaid Program and how it is an integral part and a very difficult problem for State governments. I am wondering if the Senator from Georgia thinks there might be opportunity for more bipartisan support for Senator Reid's amendment to have the Federal Government pay for 100 percent of Medicaid costs if Medicaid is expanded. Mr. ISAKSON. Well, I think the majority leader is exactly right. There is a prime example of what happens when the Federal Government mandates a benefit or a program and doesn't pay for it, the States end up having to do it. Just take No Child Left Behind or take the Elementary and Secondary Education Act, and IDEA. Back in 1978 we mandated funds to be appropriated for individuals with disabilities in America. In fact, we mandated States spend 40 percent per FTE more on a special needs child than on a regular child. We never sent them a dime for about 20 years. We finally, in 1999, started paying part of that 40 percent. Now we are only paying half of it. So now we take Medicaid. Medicaid is a program, for the people out there who are listening today, where the States pay about one-third of Medicaid and the Federal Government pays about two-thirds. It changes a little bit, but that is about right. The State runs the program; the Federal Government mandates the program. When I was first elected to the Georgia Legislature, the expenses for Medicaid the year I was elected in the State budget were $20 million, State funds. That was 1 percent of the State's $2 billion budget. Now, today, this year, even with all of the cuts that have taken place, Medicaid is 12 percent of Georgia's budget. So it has grown from 1 percent of the budget to 12 percent of the budget in about 30 years. Plans in the health care bill that are being talked about in the Finance Committee and that have been talked about in the House would mandate an increase of 150 percent -- from 100 percent of poverty to 150 percent of poverty for Medicaid eligibility. It is said the States will be held harmless until 2013 or 2014, but no promises after that. Let me tell my colleague what would happen to my State of Georgia if we raised mandatory eligibility to 150 percent of poverty and the State paid its third of that one-third, two-thirds matched by the Federal Government. It would raise Georgia's Medicaid budget expenses annually from 12 percent of our budget to 20 percent of our budget, $3.32 billion. States can't afford to do that. As the Governor of Nevada said, 43 of our States can't deficit spend; 43 percent of our States must balance their budgets. Medicaid has been carved on and worked on as it is to try and preserve it under the existing law. With a 150-percent increase in eligibility and no funds from the Federal Government guaranteed, the States would be put in a position of spending one penny out of every five on Medicaid, which is about 12 percent of my State's population. That is disproportionate and it is not fair. I think Senator Reid is exactly right. Our States should be held harmless on any mandated increases in Medicaid. Mr. ALEXANDER. Mr. President, going back to the Senator's point, the thing I think about, those of us who have been a Governor or in the legislature -- in fact, I have said to some of my colleagues many times that if we expand Medicaid for low-income Americans -- which States have to pay a third or more of -- without paying for it, that we Senators ought to be sentenced to go home and serve as Governor for 8 years to see what it is like. I mean that because I can remember as Governor for 8 years balancing budgets, first I would come up with the money for kindergarten through the 12th grade -- that was a pretty set amount -- then for the highways, and then for the prisons, and I would get down toward the end and there would be a certain amount of money left to either go into higher education or it would go for increasing Medicaid costs. Almost always that was the choice. If I put it into Medicaid, I had to take it out of education, and that would keep the University of Tennessee or Georgia or the community colleges from getting better. Guess what happens when the State can't put the money in. The tuition rates go up. Mr. ISAKSON. It is interesting you talked about that. By the way, your experience as Governor was a great experience for Tennessee, and your leadership in education was phenomenal. But already with the restricted economy we have today and the recession in my State, our teachers this year are having to take a minimum of 3, and at the university system a maximum of 6, furlough days without pay just to try and meet the balanced budget. Part of that is the pressure of Medicaid, which is an entitlement. We cannot decide to just not pay Medicaid, we have to do it. It is a Federal law; the State has to run it. What the States are having to do this year -- my State of Georgia and I think the State of Tennessee has probably experienced some of the same thing -- they are having to cut back on other programs in order to still manage Medicaid. In a State, when they say "other programs," they are talking first and foremost about education. In Georgia, 54 percent of the budget is the university system and elementary and secondary education, one out of every two cents. Well, if they can't cut Medicaid because it is an entitlement, then they have to cut education first and foremost, which is the most important function of State government. So the unintended consequences of such a mandate are going to be devastating. They only have two choices: to continue to cut education or to raise taxes. Neither one of those are a good choice. Mr. ALEXANDER. There is an article in the New York Times today which I ask unanimous consent to have printed in the Record. Mr. ALEXANDER. Mr. President, the headline is "Rate of Enrollment in Medicaid Rose Rapidly, Report Says." The recession is driving up enrollment in Medicaid at higher than expected rates, threatening gargantuan State budget gaps -- This is the New York Times; this is not the Republican Party saying this -- even as Congress and the White House seek to expand the government health insurance program for the poor and disabled. It goes on to say: As unemployment surged, enrollment in State Medicaid programs grew by an average of 5.4 percent in the previous fiscal year, the highest rate in 6 years...in eight States, the growth exceeded 10 percent. Three-fourths of the agency directors of Medicaid said they already fear their appropriations will not be enough and that lawmakers will have to find more money or, more likely, cut benefits or provider payments. One such State is Nevada. The home State of the majority leader. We're seeing the trajectories of our enrollment growth as well as our revenues all going in the wrong direction --Said their head of financing. State budgets were buffered from even worse pain by the stimulus package, but the New York Medicaid director said her State would face a $5 billion annual gap and would have to consider deep cuts in home and personal care, and that is before we make any changes or add any costs. When the Federal Government talks about adding State Medicaid costs: Three-fourths of the Medicaid directors -- The New York Times said -- said they thought the changes might deepen their budget holes. What do you suppose in Georgia -- already struggling in the way you have just described -- would happen if -- and this is why we said we insist on reading the bill before we vote on it and knowing how much it costs before we vote on it. We want to know exactly what the provisions are because I hear that States will be required to pay 5 to 22 percent in the first 5 years of the Medicaid expansion, and then after 5 years they might have to go up to 35 percent or so. What do you suppose will happen to Georgia if these kinds of costs are added to the State budget? Mr. ISAKSON. I will tell you a little story that happened in the month of August that is indicative of what is going to happen in Medicaid services if we have the continuing pressure. I was in Forsyth, GA. It is about halfway between Macon and Atlanta. I had done a speech at the Law Enforcement Training Center and decided to go into the local sandwich shop in downtown Forsyth and have a sandwich and greet people and say hello. I had greeted people and said hello. There were about 10 of them in the room. I went up to get my sandwich. When I came back this lady had circled all the tables around and saved a seat for me, and said: Senator, we are going to have a townhall meeting. They started talking to me about their concerns. Toward the end of the meeting, one gentleman at the end of the table finally said: Senator, I want to tell you a story. I am a pediatric ophthalmologist. I am the last pediatric ophthalmologist who takes Medicaid patients. He said: I just want to tell you what is happening because of the pressure on Medicaid expenses. He said: I have a child right now who has a condition where if it is not addressed, the child will go blind. There is a medicine, it is very expensive, but it can restore the cornea and the lens and help that child to be able to see. We have submitted it three times to Medicaid, and they will not pay it. It is the only drug. There is not an option. There is not a generic substitution. It is one of the breakthroughs. So what we have already going on in health care and in our entitlement programs, but in particular in Medicaid, is we try and manage the expense by lessening the amount we reimburse. The unintended consequence of that is we lose physicians who finally say: I am just not going to take Medicaid patients anymore. Then, the ones who finally are doing it, then we start to see what they submit as a treatment not being approved for reimbursement. So the unintended consequence of putting even more pressure on the Medicaid system is going to put more pressure to ration health care for all Medicaid patients, and that is not fair nor is it right. Mr. ALEXANDER. No, it is not fair and right. The Governors have said, Democratic and Republican Governors -- and you raised a second point about this Medicaid expansion: that dumping millions more low-income Americans into Medicaid is not health care reform because Medicaid, as the Senator just pointed out, so poorly reimburses the doctors and the hospitals that about 40 percent of doctors will not see Medicaid patients. So when we say to someone: Congratulations, we have just fixed the health care system. We have dumped you into Medicaid -- you are giving somebody a bus ticket to a bus system that operates 60 percent of the time. So the first thing we are doing with the proposal as it is coming toward us is we are -- and I am not exaggerating -- we are potentially bankrupting States. Speaking of States, let me just share one letter, Senator Isakson, from the Governor of California. This is a State that has really struggled with its budgets. They have a number of problems. Here is what the "Terminator" has to say. He wrote to Senator Reid and to Senator McConnell on the Republican side and Speaker Pelosi. It is a long letter. This is the basic idea. Arnold Schwarzenegger says:I will be clear on this particular proposal: if Congress thinks the Medicaid expansion is too expensive for the federal government, it is absolutely unaffordable for states. Governor Schwarzenegger goes on to say:Proposals in the Senate envision passing on more than $8 billion in new costs to California annually -- crowding out other priorities or constitutionally required state spending and presenting a false choice for all of us. I cannot and will not support federal health care reform proposals that impose billions of dollars in new costs on California each year. I ask unanimous consent that this letter be printed in the Record. Mr. ALEXANDER. Madam President, I say to the Senator from Georgia that we are not being clever when we say we would like to be cosponsors of the Harry Reid amendment. The problems of the States are so well documented today. They don't just exist in Nevada or the two or three other States he picked out yesterday; they exist in California, which is now not part of the Reid amendment. I guess that Senators Feinstein and Boxer would be happy to cosponsor the Reid amendment if it included California. I certainly would be if it included Tennessee. I know the Senator from New York and others would be also. Our States cannot afford to have the Federal Government say: We are going to expand your health care, Mr. and Mrs. Low-Income American.. It is not a very good health care program. And then we are going to send 40 percent of the bill to States that are already bankrupt, making it more difficult for them to provide good care. Mr. ISAKSON. The Senator from Tennessee has said frequently over the last couple of months that what we really need to do is take a step-by-step approach. Comprehensive health care reform's unintended consequences will be a disaster because it affects 17 percent of the economy. You are taking the entitlements and 86 percent of the people who have some coverage and you are threatening that they have to go into a government option. This Medicaid debate is a good example of how we need to take a step-by-step approach, we need to take first things first. In the report before our committee, the HELP Committee, on which we serve together, we spent 67 1/2 hours in the markup on that bill during the months of June and July. We heard about the uninsured and the uncovered in America. Of that 14 to 16 percent we hear about, a number of them are Medicare or Medicaid eligible, and they are not enrolled. So the first step we ought to take is to say we are going to create a mechanism where every Medicaid-eligible person and Medicare-eligible person is covered, which would probably mean that when someone visits a hospital because they are ill and they are qualified for Medicare or Medicaid, they get enrolled automatically so that they do have the coverage. That is the first step we ought to take in terms of entitlement. Then we can take another part of the uninsured -- those people you and I talk about, the independent contractors, small businesspeople -- and we can allow the forming of risk pools across State lines and insurance sales across State lines and allow like professions to associate together to form larger risk pools to compete with major corporations. And then insurance becomes more accessible and affordable. This debate we are having over Medicaid and the Governors' immediate reaction -- which is 100 percent of the Governors, not just a couple -- demonstrates to us that we need to slow down and take step-by-step approaches to begin addressing the uncovered and uninsured without creating unintended consequences that bankrupt States and ration health care. Mr. ALEXANDER. The Senator is being very sensible. I think most Americans would agree with us that our goal is to reduce the costs of health care -- reduce the costs of your health care insurance when you buy it and reduce the costs to your government that is running up a big debt every year. The Senator from Georgia mentioned two specific ways we can take steps in the right direction without getting into this business of taking over so much in Washington, with trillions of dollars of debt, passing on big taxes to States, and cutting Medicare and threatening seniors in a whole variety of other ways. One was to allow small businesses to pool their insurance so they could offer more to their employees. That could affect millions of Americans. Another was to sign up more people who are already eligible. Another is to do something about junk lawsuits against doctors that are driving up costs. Another is to create more insurance exchanges in the States. We have proposed these. People say: Where is the Republican plan? If they are looking for some comprehensive, trillion-dollar, thousand-page bill, they are not going to see it. If they are looking for four or five practical steps to move in the right direction, we talk about that every day, and we are not afraid to warn against the big, thousand-page bill plans. We compliment the Senator from Nevada for recognizing that it would ruin his State if we passed this bill, and we hope we have the opportunity to cosponsor that amendment so it applies to every State. Mr. ISAKSON. There is no question -- when the Senator referred to independent contractors, I had a flashback to my 33 years in business. For 22 of those years, I ran a real estate brokerage company. I had accountants, secretaries, and backroom operators. All my salespeople were independent contractors. I provided group medical under ERISA for my secretaries, backroom operators, and my employees, but the Federal law -- the IRS Code -- prohibits an employer from providing health care to an independent contractor. So here we have another unintended consequence of a Federal mandate that says to somebody: Simply because of the way in which you establish yourself and earn your income, some people can get group medical coverage and some cannot. In the case of those who worked for me, it forced second-career, middle-aged people not to be able to participate in a group policy. They had to buy insurance in the spot market. That spot market in health care is expensive because there is no shared risk. You don't have young people, older people, and well people to balance the cost of the pool. You have one individual who, if they already have health problems, may be uninsurable because of a preexisting condition. It is important that we look at the existing unintended consequences in the Tax Code that prohibit companies from being able to offer group medical insurance to the independent contractors who work for them. Mr. ALEXANDER. That is exactly right. As we think about Senator Reid's amendment and also the step-by-step proposals, one way to describe his amendment is to say to Nevada -- and Oregon, Rhode Island, and Michigan -- that we are going to pay 100 percent of your Medicaid costs. That is a step in the right direction. I think that is the way I should characterize that. That is not a criticism of the majority leader. That is saying: Mr. Majority Leader, you are going in the right direction, but you didn't include Tennessee, and Tennessee is not expected to recover to the 2008 levels until 2014. State employees won't receive raises for 6 years, the reserves will be depleted, and there will be no new construction projects. Our Governor, a Democrat, said this proposal is the mother of all unfunded mandates. So I think Tennessee Senators would like to be included in the Reid amendment. I imagine the Texas Senators would too. The Texas Medicaid office says the proposal would cost their State $20 billion over 10 years if we here expand Medicaid there and make them pay for a third or 40 percent of that. The South Carolina Governor says it would cost their State $1.1 billion over 10 years. I imagine those Senators would like to be a part of this. The Alaska Governor says it would cost $140 million in State general funds. I imagine the Alaska Senators would like to cosponsor the amendment. Governor Schwarzenegger -- I suppose his Senators would like to be part of this as well. The Nebraska Governor says this could mean higher taxes in Nebraska, cutting State aid to Nebraska school districts as well as State appropriations to universities. This proposal is not in Nebraska's best interest. The South Dakota Governor said so as well. This is serious business for the States. It is easy, when you come to Washington, to forget about the States. In the States, if you are a Governor or if you are a legislator, as the Senator from Georgia and I have been, you have to put all your responsibilities out there ahead of you. The first one is education. You take the available money and spend it as best you can and you balance your budget. Then you look up to Washington, and here comes some Congressman or Senator saying: I have a great idea; let's expand health care all over your State and you will pay for it. That is called an unfunded Federal mandate. It is the wrong thing to do. The Senator from Nevada noticed it in his State. All States would like to be part of that amendment. Mr. ISAKSON. I agree. You cannot just treat 4 States differently from the other 46. You have to treat everybody alike. I say to Senator Alexander that there is another step-by-step thing we ought to talk about. In the pay-fors -- the Medicaid increase of 150 percent is a pay-for. Mr. ALEXANDER. You mean – Mr. ISAKSON. It is part of the cost of insuring everybody. There is another one; that is, the assumed $500 billion in savings from waste, fraud, and abuse in Medicare. I got a phone call – Mr. ALEXANDER. That often confuses people. Medicaid is the program we have been talking about, of which States administer and pay a third or 40 percent. That has about 59 million people in it. The proposal is to move it to where one out of four Americans would be on Medicaid. There is also Medicare, which has about 40 million people, all seniors. Mr. ISAKSON. This is my Medicare month. I am supposed to enroll. So it is now a personal issue with me. Mr. ALEXANDER. That is the way it is with most Americans. It has become a personal issue, and I think that is why so many people are going to townhall meetings. Mr. ISAKSON. I did a telephone townhall meeting, and a fellow said: Senator, I have a question for you. If there is $500 billion in savings in Medicare, why aren't you all using it now to help save Medicare instead of giving it to another program to pay for it? Medicare is going broke by 2017. Mr. ALEXANDER. Yes, and that is not just a casual statement. Those are the Medicare trustees, whose job it is to look over the Medicare money, who are saying it is going broke by 2015 to 2017. Mr. ISAKSON. They are saying it is over. So we are selling a revenue saver to pay for the expansion of health care at the Federal level by saying we are going to reduce payout for seniors in Medicare by $1/2 trillion in waste, fraud, and abuse. Well, assuming we know there is $1/2 trillion there, it ought to already be cut out and it ought to be going into the Medicare trust fund to shore it up so it lasts longer than 2017. We should never promise we are going to pay for something on something we think is there and then just move the numbers down for the convenience of making a sale today. I think, as a senior, and on behalf of all seniors, we all realize if that $1/2 trillion isn't there in waste, fraud, and abuse, the first thing you are going to do is have reimbursements cut; the next thing, instead of three out of four doctors taking Medicare patients, it will be only be two out of four or one out of three; and pretty soon the next thing is that seniors will have health care that is inaccessible and their doctors will not be available. That is a dangerous road to go down. Mr. ALEXANDER. I hear our friends on the other side say: Republicans are trying to scare you about Medicare cuts. We are not trying to scare anybody about Medicare cuts. We just listen, and the President said in his speech to us that the savings for this program -- nearly $1/2 trillion in savings to pay for the new program is coming from savings in Medicare. That is Medicare cuts. We know the specific proposals are $130 billion in cuts to Medicare Advantage, which one out of four Medicare seniors has; $120 billion in Medicare cuts to hospitals; $40 billion to home health agencies; $8 billion to hospices. Our point, if I am correct about this -- and if I am not, please correct me -- of course there could be savings in Medicare, in the growth of it, but if we have savings in Medicare, we ought to put the money into Medicare; we ought not to take it from grandma and spend it on somebody else. That is the problem. The other day, the Senator from Kansas said it is like writing a check on an overdrawn bank account to buy a big, new car. Whatever money we ought to have ought to go in the overdrawn bank account, which is Medicare. Mr. ISAKSON. That is correct. Social Security is another example of what happens when you don't have good fiscal discipline. Unfortunately, for the better part of half a century, when people have paid their FICA taxes to go into the Social Security trust fund, it goes in and then immediately it is replaced by an IOU and the money is moved to general appropriations and spent. That is why Social Security is going broke in 2037. I just got my statement last week, and on the cover -- everybody ought to read their Social Security letter, the column on the right-hand side which tells you what the trustees are telling you about the solvency of Social Security. We cannot make any more hollow promises to the American people. We have to keep the promises we have made, and those promises are Medicare, Social Security, and Medicaid. So instead of expanding things we already can't afford, we need to be finding ways to stabilize them before we run off and make a promise we can't keep. Mr. ALEXANDER. Madam President, how much time do we have remaining? The PRESIDING OFFICER. There is 13 minutes 54 seconds remaining. Mr. ALEXANDER. Two minutes fifty-four seconds. If the Senator from Georgia will permit me, I ask unanimous consent to put in the Record the following – The PRESIDING OFFICER. The Senator has 13 minutes remaining. Mr. ALEXANDER. I thought you said 2 minutes 54 seconds. We will continue. I remember former Senator Warner once said when he first came to the Senate, he was sitting there wondering what to do. One of the older Senators came over and said to him: Son, you will have no trouble getting used to this. All you have to do is stand up and start talking and eventually you will think of something to say. I think we have something of considerable importance to say. What we are saying is we need health care reform and the focus should be on reducing costs and we ought to go step by step toward those costs. That is our proposal, instead of these big, comprehensive, trillion-dollar, 1,000-page bills with all these unintended consequences. We are talking about one of those unintended consequences, which is a very severe consequence for the States. The idea that Senators and Congressmen would decide to expand a program that is going to cover one out of four Americans, called Medicaid, and just send the bill to the States which, according to today's Wall Street Journal: "plunging state revenues noted that the second quarter was the worst performance for state taxes since at least the 1960s." This is not just Nevada and Michigan and Oregon and Rhode Island, which are the four States that were in the majority leader's amendment.. This is virtually all the States. If the Senator from Georgia will indulge me for a moment, I have several letters from Governors to Senators that I ask unanimous consent to have printed in the Record at the end of our remarks. The ACTING PRESIDENT pro tempore. Without objection, it is so ordered. (See Exhibit 1.) Mr. ALEXANDER. Madam President, here is a letter to Mr. Bill Nelson, a Senator from Florida, from Gov. Charlie Crist, talking about enrollment in Florida's Medicaid Program increasing and how the State of Florida cannot afford to spend more. I have a letter from Governor Otter of Idaho to Senator Crapo: "It has been estimated that combined federal-state Medicaid costs in Idaho could increase by $501 million." I have a letter from Governor Daniel of Indiana to Senator Lugar which says: "We have estimated that the price for Indiana could reach upwards of $724 million annually." We talk about big numbers in Washington so much that maybe this doesn't sound like much. But I did an estimate of what it would cost, I say to Senator Isakson, in Tennessee if we expanded Medicaid in the way it is proposed here and we increase the reimbursement rate so patients in Medicaid will actually have somebody to go see, a doctor or a hospital to go see. I said it equaled about a new 10-percent State income tax. Some group in Tennessee said: The Senator is wrong, it is only about a 3-percent new State income tax. Well, either one, we don't want elected representatives in Washington deciding for us whether we want a new 10-percent or 3-percent State income tax. There are just a few more I wish to include. I have a letter to Senator Reed from the Governor of Rhode Island. Of course, Rhode Island was included in the majority leader's amendment. They should feel pretty good. They are going to get 100 percent of their Medicaid paid. The Governor of Arizona has written to Senator McCain and Senator Kyl to point out that "Arizona is facing one of the worst financial deficits in the nation...." If Arizona is facing one of the worst financial deficits in the Nation, why is it left out of the majority leader's amendment? It seems to me the citizens of Arizona deserve just as much attention. I imagine their Senators would like to cosponsor it as well. I have a letter from the Governor of Louisiana talking about an unprecedented fiscal situation and the Governor of Mississippi saying: In Mississippi, the issue of Medicaid expansion hits close to home, since our state's share of the Medicaid is currently $707 million.... "According to the National Association of State Budget Officers, Governor Barbour said, Medicaid expenses...were $336 billion" for State and local government and a third of that is State money, and we are just going to up it. We don't raise that money, we just send them an edict from Washington and say: We have decided that a good thing to do is to increase the number of low-income Americans in your Medicaid Program and you pay for it, you take it out of this road, you take it out of this teacher's salary, you raise the tuition at the University of Tennessee or Georgia and you cut their State funds. That is up to you, but we are going to pass the program. Here is a letter to the Senator from Nebraska saying this new unfunded Federal Medicaid mandate could result in higher taxes in Nebraska or in cutting State aid to Nebraska school districts. I imagine the Senators from Nebraska, both of whom were Governors, would be happy to be cosponsors of the Reid amendment. Here is the letter to Senator Graham from the Governor of South Carolina. Another from the Governor of Alabama; a letter from the Governor of Alaska and the Governor of Guam. I say to Senator Isakson, we have been fairly specific on one point. I heard on the television this morning someone said this is so confusing to the American people; they don't understand it. I think they can understand an unfunded Federal mandate. I think they can understand the Governor has to raise taxes unless Congress pays 100 percent of it. I think they can understand it when the majority leader picks out four States and says we will pay 100 percent of ours and the rest want to be part of that as well. Mr. ISAKSON. The American people understand. This colloquy has been helpful to demonstrate something, I say to Senator Alexander. We on the Republican side have been accused from time to time of being obstructionists on health care reform. I think we indicated this morning we have been instructive, going on a step-by-step basis, dealing with the problems manageable one at a time, not sacrificing Social Security or Medicaid or Medicare, not sacrificing our States and forcing them into the impossible position of declining revenues and increasing costs through a mandated Federal program that, in the end, is only going to result in rationing of care to Medicaid-eligible beneficiaries and more and more pressure on our States already. We are not trying to obstruct anything. We find it very instructive that there are ways, on a step-by-step basis, that we can close the gap on the number of uninsured people without taking away the benefits others always have. I thank the Senator for allowing me the opportunity to participate in this discussion. We are learning from our Governors. I have learned from my townhall meetings and from my visits in Georgia. We understand America is tuned in and a lot of America, 16 percent of it, needs attention for more affordable, accessible health care. Let's be about the business, on a step-by-step basis, of providing that and closing that gap without threatening to destroy the programs we have established over the years and promised to our seniors and to those less fortunate. Mr. ALEXANDER. Madam President, I thank the Senator from Georgia for his experience in State government and for his comments today. We want the majority leader to know our comments yesterday were not to be critical of him, just to say we think he is on the right track. He said to four States: If we expand your Medicaid, we are going to pay for it. We would like to include all States. I yield the floor.